Medicare-CDBS E-Form | Teeth On Wheels

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.

Declaration

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 $57.65, Fluoride Treatment $37.85, Clean/Scale $58.90- $98.20, Fissure Sealants $50.45, X-Rays $33.35, Fillings $126.40- $265.20

School Name:*

Patients First Name*

Patients Last Name*

Patients Date of Birth*

Medicare Details

Medicare Number*

10 Digit Number

Individual Reference Number*

Single number next to patient name

Your First Name*

Your Surname*

Email*

Please note: If you do not wish to have any treatments done, please notify the Customer Service department . If a treatment is not required for your child, we will not do the treatment.

I give Teeth on Wheels permission to do the following treatment(s) on my child if required for 2x visits in a calendar year.

Check-up/ Exam
X-rays
Clean/ Scale
Fluoride Treatment
Fissure Sealants
Fillings

Has your child's medical history changed within the last 12 months?

No
Yes

Please provide more details in regards to your childs change in medical history*

I hereby give consent for the use of my child’s photo / video material to be utilised by the company for the marketing/social media.

Yes
No

Parent/Guardian Signature*

Date Signed

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Name

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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

Medicare Details