This form must be completed correctly for you to claim The Child Dental Benefits Schedule (CDBS). To find out if you are eligible, please see our FAQ’s

  • Child Dental Benefits Schedule Bulk Billing Patient Consent

  • I, the patient / legal guardian, certify that I have been informed:

    • of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule;
    • of the likely cost of this treatment; and
    • that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.


    • I understand that I/the patient will only have access to dental benefits of up to the benefit cap;
    • I understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule;
    • I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.
    Check-up/Exam $54.05, Fluoride Treatment $35.45, Clean/Scale $55.20- $92.05, Fissure Sealants $47.25, X-Rays $31.25, Fillings $118.45- $248.55

  • Medicare Details

  • 10 Digit Number
  • Single number next to patient name
  • This field is for validation purposes and should be left unchanged.