Child Date Of Birth
Gender

MaleFemaleOther
Does your child attend School or Childcare / Kindergarten?
SchoolChildcare / Kindergarten

Days at Centre
Choose the days
MonTueWedThurFri

If you do not have Medicare please enter 12345678901 as medicare number and 1 as Ref number.

What is the Child Dental Benefits Schedule ?
You can avail Child Dental Benefits Schedule at our clinic. All children between ages 2-17 are eligible to avail the Child Dental Benefits Schedule. It is a program under the Australian Government that lets your child receive general dental services worth $1095 over two consecutive calendar years. Once you receive a confirmation letter from Medicare, you can avail the dental benefits under Child Dental Benefits Schedule.

Am I eligible for Child Dental Benefits Schedule 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.

How much does it cost in case my child is not eligible?
If your child is NOT ELIGIBLE for the Child Dental Benefits Schedule funding they can still receive treatment. We can offer a comprehensive oral examination and a parent report for $50 or a comprehensive oral examination and a clean (removal of plaque & calculus) and a parent report for $80. f you have private health insurance, we will provide you with a receipt to claim back with your private health insurance directly.

Please choose if your child had/has any of the following medical conditions. If you select a condition, please supply further information if necessary. Known medical conditions:
ADHDArtificial Heart ValveAsthmaAutismBleeding DisorderChronic ConditionsDiabetesEpilepsyHepatitis A, B or CHeart ConditionsHigh/Low Blood PressureInfectious Disease/sKidneyConditionsTuberculosisOtherNone

Does your child have any allergies?
YesNo

Is your child currently taking any medications?
YesNo

Are there any main dental concerns for your child?
YesNo

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

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 daily1-2 times daily3+ more times daily
When does your child usually consume sugary drinks and snacks?
Between mealsDuring meals
What is the usual source of drinking water for your child?
TapWell/Tank waterBottled waterOther

How many times a day does your child brush their teeth?
Less than 1 time daily1 time daily2 times daily3 times or more daily
Does your child have their own toothbrush?
YesNo
Does your child use a toothpaste with fluoride in it?
AlwaysSometimesRarely or never
Does your child brush their teeth before they go to bed at night?
AlwaysUsually/SometimesRarely or no

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 do the following treatments on my child if required:
Please note: If you do not wish to have any treatments done, please call us on 0469 041 783. If your child does not require a certain treatment consented by you, we will not do the treatment.
Check-up/ExamClean/ScaleFluoride TreatmentFissure Sealants
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 parent report that will outline what treatment was completed on the day and if any further treatment is required for your child. If something urgent is required for your child, we will contact you via phone to discuss further.
Please tick the appropriate boxes if you wish to proceed
If ELIGIBLE FOR Child Dental Benefits Schedule, conduct an oral examination ($52.65), Clean -removal of plaque ($53.80) or calculus ($89.70) and application of re-mineralising agent ($34.55) as required. The treatment carried out on the date will be BULK BILLED and covered by Child Dental Benefits Schedule.
If the child is NOT Eligible, do you still wish to proceed with the Dental visit?
YesNo
IF Yes
If NOT ELIGIBLE FOR Child Dental Benefits Schedule, please provide an oral examination & parent report for a fee of $50 ORIf NOT ELIGIBLE FOR Child Dental Benefits Schedule, please provide an oral examination, removal of plaque/ calculus (clean) & a parent report at a fee of $80

If NOT ELIGIBLE for Child Dental Benefits Schedule and have Private Health Insurance, a receipt will be provided for the option chosen above and can be claimed back from your private health fund depending on the level of your health cover.
Reminder:
Would you prefer a courtesy call or SMS text to remind you of your appointment?
Courtesy CallSMS reminderBoth

Credit Card Type
MasterCardVisa

I, the patient / legal guardian, certify that I have been informed:
Please check all boxes
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;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 availabel under the benefit cap.

Please check all boxes
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 availabel benefit cap and that I will need to personally meet the costs of any additional services once the benefits are exhausted.of the likely cost of this treatment;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 availabel under the benefit cap.
Check-up/Exam $54.05, Fluoride Treatment $35.45, Clean/Scale $55.20- $92.05, Fissure Sealants $47.25.

Please check this box
Yes, I have read and understand the information listed above

By signing this form I, the patient/legal guardian certify that:
Please check all boxes
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 by completing this form, I give permission to Smile For Kids to see my child for 2 visits in this calendar year.