How to Find Us / Give Us Feedback
+61 469 041 783
info@smileforkids.com.au
Your child smile is our top priority
First Name Of Child
Last Name Of Child
Child Date Of Birth
Gender (*) MaleFemaleOther
Does your child attend School or Childcare / Kindergarten? SchoolChildcare / Kindergarten
Name of the Childcare/Kindergarten/School
Any siblings at the centre? YesNo
Days at Centre MonTueWedThurFri
Child's Medicare Number
Child's Individual Reference Number
If you do not have Medicare please enter 12345678901 as medicare number and 1 as Ref number.
Child Dental Benefits Schedule Children aged 2-17 may be eligible for up to $1095 in general dental services over two calendar years. We will check eligibility after the form is completed. For Medicare enquiries, please call 132 011.
If your child is not eligible You may still proceed with treatment. Available private fees include examination and parent report ($60), examination, clean and parent report ($90), or fissure sealant per tooth ($45). A receipt can be provided for private health insurance claims.
Parent First Name
Parent Last Name
Relationship With Child
Mobile Number
Address
Email
Any medical conditions? eg: Asthma, ADHD, autism
Any allergies? eg: latex, dairy intolerance, milk allergy
Is your child taking any medication?
Do you have any dental concerns for your child?
When was your child's last dental visit?
Any habits? eg: thumb sucking, dummy, bottle feeding
In accordance with the Australian Privacy Principles, 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 purpose of marketing/social media. YesNo
I give permission to Smile For Kids to provide the following treatments if required. If you do not wish to consent to treatment, please call 0469 041 783. Check-up/ExamClean/ScaleFluoride TreatmentFissure Sealants
Treatment will only be completed if required. You will receive a parent report after the appointment, and we will call you if urgent treatment needs discussion.
Please tick the appropriate boxes if you wish to proceed If eligible for Child Dental Benefits Schedule, provide required examination, clean, re-mineralising agent and fissure sealant. Treatment will be bulk billed subject to available benefits.
If the child is NOT Eligible, do you still wish to proceed with the Dental visit? YesNo
If yes, please select one main option Comprehensive oral examination and parent report - $60Comprehensive oral examination, clean and parent report - $90
Optional add-on treatment Additional fissure sealant per tooth - $45
If not eligible and you have private health insurance, a receipt will be provided for your claim.
Credit Card Type MasterCardVisa
Card Holder's Name
Card Number
Expiry
CVV
Please check all boxes
I have been informed of the treatment that has been or will be provided under the Child Dental Benefits Schedule. I have been informed of the likely cost of treatment. If eligible, I understand the treatment will be bulk billed subject to sufficient funds being available under the benefit cap. 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 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 the 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 the benefits are exhausted. I understand 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.
Check-up/Exam $54.05, Fluoride Treatment $35.45, Clean/Scale $55.20- $92.05, Fissure Sealants $47.25.
Are you happy for us to proceed with dental check-up in the next six months? YesNo
Sign Date
Parent/Signing First Name
Parent/Signing Last Name
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