Consent eForm | Teeth On Wheels

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Child Details

First Name*

Last Name*

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

Other

Does your child attend School or Childcare / Kindergarten?*

School

Childcare / Kindergarten

School Name*

Class / Grade*

Childcare / Kindergarten Name*

Location / Suburb

Room / Group

Days attended

Monday

Tuesday

Wednesday

Thursday

Friday

Medicare / Private Health and Payment Details

Do you have a Medicare card?

Yes

Medicare Number*

10 Digit Number

Individual Reference Number*

Single number next to patient name

What is the Child Dental Benefits Schedule (CDBS)?

With assistance from the Federal Government, Medicare has introduced a Child Dental Benefits Schedule (CDBS) that provides children access to basic dental services from the ages of 2-17 years old. The entitlement is capped at $1,095 per child for every two calendar year period.

Am I eligible for CDBS and how do I claim?

To be eligible, you or the child must be claiming one of the following benefits: Family Tax Benefits-Part A, Parenting Payment, Abstudy, Youth Allowance, Carer’s Payment, Disability Support Pension, Special Benefits or Double Orphan Pension. To enquire if your child is eligible, please contact Medicare on 132 011.

Once your child’s forms have been completed, we will individually check each child’s eligibility to see if treatment can be bulk billed through Medicare.

If my child is not eligible for the CDBS, how much does it cost?

If your child is not eligible for the CDBS funding, Teeth on Wheels can offer a check-up, clean and fluoride treatment (and x-rays if required) for only $99 per visit. If you have Private Health Insurance, Teeth on Wheels will provide you with an invoice after your $99 payment to claim your refund.

Parent, Guardian or Emergency Contact Details

First Name*

Last Name*

Parent or Guardian Phone Number*

Landline

Mobile

Parent or Guardian Landline*

Parent or Guardian Mobile*

Street Address*

Suburb / City*

State*

Postcode*

Email*

Medical History

Please choose if your child had/has any of the following medical conditions. If you select a condition, please supply any further information.

Known Medical Conditions

ADHD

Artificial Heart Valve

Asthma

Autism

Bleeding Disorder

Chronic Conditions

Diabetes

Epilepsy

Hepatitis A, B or C

Heart Conditions

High/Low Blood Pressure

Infectious Disease/s

Kidney Conditions

Tuberculosis

Other

Other or further Information including operations:

Does your child have any allergies?*

Yes

Please provide additional information below*

Is your child currently taking any medications?*

Yes

Please provide additional information below, including if an Epipen is required?*

Are there any main dental concerns for your child?*

Yes

Please provide additional information*

Oral Health Status

How would you describe the condition of your child’s mouth and teeth? Would you say…

Excellent

Very Good

Good

Fair

Poor

Diet Analysis

Does your child consume sugary drinks/ snacks? ( E.g. Soft drink, fruit juices, flavoured milk, lollies, biscuits, chocolates etc.)

Less than 1 time daily

1-2 times daily

When does your child usually consume sugary drinks and snacks?

Between meals

During meals

What is the usual source of drinking water for your child?

Tap

Well/Tank water

Bottled water

other

Oral Hygiene Behaviour

How many times a day does your child brush their teeth?

Less than 1 times daily

1 Times daily

2 Times daily

3 times or more daily

Does your child have their own toothbrush?

Yes

Does your child use a tooth paste with fluoride in it?

Always

Sometimes

Rarely or never

Does your child brush their teeth before they go to bed at night?

Always

Usually

Sometimes

Rarely or no

Social Media / Marketing Consent

In accordance with the Australian Privacy Principals, Part 2 - Collection Of Personal Information.

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

Treatments

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:*

Check-up/Exam

X-Rays- (Recommended to complete a thorough comprehensive examination)

Clean/Scale

Fluoride Treatment

Fissure Sealants

Fillings

Please note treatment will only be completed if it is required and treatment descriptions are disclosed on our website. After your child's appointment you will receive a letter which will outline what treatment was completed and if anything further is required. If your child requires anything of urgent matter, you will receive a call.

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

Patients First Name*

Patients Last Name*

Medicare Number*

10 Digit Number

Individual Reference Number*

Single number next to patient name

Parent/Guardian Signature*

Date Signed

First Name of person signing*

Last Name of person signing*

Patient Consent

Declaration- By signing this form I, the patient/legal guardian certify that: I have completed the form to the best of my knowledge, I understand that failure to make a full disclosure may place my child at undue medical risk or compromise their treatment, I give my child permission to leave the facility to attend the Teeth on Wheels mobile dental clinic with a member of staff, I give Teeth on Wheels permission to share this consent form with my child's facility, I understand that by completing this form, I give Teeth on Wheels permission to see my child for 2 visits in this calendar year*

Yes, I have read and understand the information listed above