Patient Consent Form

Patient Details

Child's First Name *

Child's Surname *

Date of Birth *

Gender *

Childcare / School Name *

Parent / Guardian Details

Parent / Guardian Full Name *

Relationship to Child *

Email Address *

Phone Number *

Home Address *

Dental Information

Last dental visit

Brushing/Flossing Frequency

Teeth Grinding

Thumb/Dummy Sucking

Any concerns about your child's teeth and oral health

Medical History

Please tick if any apply:

If yes to current medications, please specify:

Medicare Details

Medicare Card Number

IRN/Ref (next to name)

Expiry Date

Child Dental Benefits Schedule (CDBS) Information

Dental care for children in NSW: All children can receive free public dental services in NSW. Some children may also be eligible for the Australian Government's Child Dental Benefits Schedule (CDBS), either way, they will receive the same high standard of care at no cost to you.

What is CDBS? The CDBS is administered by the Australian Government and gives eligible children access to up to $1,132 worth of dental services over 2 calendar years.

For more information, visit health.nsw.gov.au/cdbs

Child Dental Benefits Schedule 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 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.

Patient's Full Name

Patient's Medicare Number

Parent/Guardian Declaration

I confirm the information provided is true and accurate about my child including any medical conditions which may affect dental treatment.

I consent for Shlama Dental to provide mobile dental services including examination, cleaning, fluoride application, fissure sealant if required, oral health education and dental report.

Payment Options

Please select ONE of the following payment options and tick the box under:

Child Dental Benefits Schedule (CDBS)

I confirm my child may be eligible for the Australian Government Child Dental Benefits Schedule (CDBS). I consent for Shlama Dental Clinic to check eligibility and claim benefits on my behalf. I agree to allow my child to receive dental examination, cleaning, fluoride treatment and fissure sealant if required from Shlama Dental under CDBS.

Private Health Insurance

I confirm my child is covered by private health insurance. I consent for Shlama to claim via private insurance on my child's behalf and to pay any gap amount based on our level of cover.

Insurance Provider

Membership/Customer Number

Patient Number / Card Rank

Card Issue Number (if applicable)

Private Payment

I agree to pay a $85 fee for my child's dental check-up, cleaning and fluoride treatment provided by Shlama Dental. If my child requires any further treatment, Shlama Dental will contact me before proceeding.

Parent / Guardian Signature

Signature *

Full Name *

Date *

Form Submitted Successfully!