Consent Form for Dental Treatment

We are now offering students an examination and treatment at an Oral Health Facility near your child’s school with no out of pocket costs to you.

Child Eligibility Criteria

Is eligible for Medicare and the child dental benefits schedule (CDBS) (0yrs-18yrs), or
Is eligible for Medicare and be aged between 4 years to the end of Grade 10, or
Is eligible for Medicare and be listed on a valid Centrelink Concession Card (All ages)

To check eligibility for CDBS click here

Please note :

A parent/legal guardian needs to complete this consent form prior to the child attending an appointment or attend the appointment with the child in person.

To accept this offer of treatment, please complete the below details and click submit.

Please have your Medicare card ready

If eligible, you will be contacted by Oral Health Services staff to arrange an appointment

Patient Details

Medicare Card: *

Individual Reference no. (IRN): *

Expiry date: *

Is the child on a Health Care Card (HCC) or Pension Concession Card (PCC)?

Health Care CardPensions Concession CardNeither

Pension Concession Card Number:

Health Care Card Number:

Expiry Date:

Title: *

First Name: *

Middle Name(s):

Last Name: *

Date of Birth: *

Gender: *

Street Address: *

Suburb: *

Post code: *

State: *

Parent/Legal Guardian Details

Parent/Legal Guardian First Name: *

Parent/legal Guardian Last Name: *

Relationship to child: *

Phone: *

Email Address:

Is your child of Aboriginal, Torres Strait Islander or South Sea Islander origin? *

Neither Aboriginal nor Torres Strait Islander originAboriginal but not Torres Strait Islander originTorres Strait Islander but not Aboriginal originBoth Aboriginal and Torres Strait Islander origin

In which country was your child born: *

AustraliaAnother (Please state)

Country of birth:

Language spoken: *

Interpreter required? *

YesNo

Interpreter language required:

Child's School *

Grade: *

HUB CLINIC

SCHOOL CODE:

Is this child in custody of Department of Child Safety? *

Yes (If yes, please provide details)No

Authority to care document

Browse

Medical History

If 'yes' to any of the above

GP Details

Does your child see a regular GP? *

YesNo

GP Practice Name:

GP Name:

GP Address:

Street address:

City:

State:

Postcode:

GP Phone:

Tough Teeth Fluoride Varnish Program

At times, we also conduct a screening service (Tough Teeth Fluoride Varnish Program) where a parent/legal guardian does not need to be present. At this screening, your child will receive oral hygiene instruction, dietary advice and a fluoride varnish (5% sodium fluoride) application. Click here for more information on fluoride varnish. The oral health team will notify you if any follow up dental treatment is recommended. The oral health team will liaise with your child’s school for dates for screenings.

Consent

I, the parent/legal guardian, *

Give consent for patient *

To receive:

Dental exam *

YesNo

Dental x-rays *

YesNo

Cleaning and polishing of teeth *

YesNo

Application of topical fluoride *

YesNo

Oral health screenings and oral health education up to twice yearly (Tough Teeth FVP)

YesNo

Fluoride varnish applied up to twice yearly (Tough Teeth FVP)

YesNo

I consent to receiving contact from Oral Health Services by SMS and/or email

YesNo

I understand that I can withdraw my consent at any time: *

The oral health team will notify you if any follow up dental treatment is required

Child Dental Benefits Schedule

Quote for bulk-billing to Medicare (CDBS), treatment is bulk billed with no out-of-pocket expenses for your family.

Choosing to use your child's CDBS benefit with our service helps to provide and improve the School Dental Service.

88011 - Comprehensive oral examination

88114 - Removal of calculus

88121 - Topical application of fluoride

88022 - Intraoral radiograph

88161 - Fissure sealing

Please refer to link for fee schedule on CDBS here

Once your child has exhausted their CDBS entitlements they are still eligible to access our free service.

Patient's Medicare number

Patient / legal guardian signature *

Clear

Patient's full name

Full name of person signing (if not patient) *

Date signed *

This form is valid up to 31 December of the calendar year for which it is signed

Metro North Hospital and Health Service (Metro North) is committed to ensuring the privacy, security, accuracy, and integrity of personal information regarding all patients and individuals and agents associated with receiving or providing Metro North services. To protect your personal information, Queensland Health staff must follow the privacy principles contained in the Information Privacy Act 2009 (Qld) Staff are also bound by Part 7 of the Hospital and Health Boards Act 2011 (Qld) Your personal Information is being collected by way of this form to provide you with oral health services. The personal Information provided by you will be securely stored and made available to appropriately authorised staff of Queensland Health.Your personal information may also be disclosed to health practitioners who have in the past or will provide you with care or treatment, to staff of Queensland Health for the purpose of conducting assessment of the services provided to you or otherwise for the purpose relating to providing you with public sector health services. Personal information recorded on this form will not be used or disclosed to other parties without your consent, unless authorised or required by law.By ticking the box, I consent to Metro North Oral Health Service (MNOHS) collecting and using the information supplied while offering and providing dental treatment. I acknowledge that I have legal capacity to consent to treatment being provided for the patient whose details are recorded on this form. I acknowledge, understand and consent to the data being stored on the Snapforms Platform (as a Certified Cloud Service) which may include storage held within Australia. All information will be treated confidentially and only used for the purposes outlined above.For information about how Queensland Health protects your personal information or learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.
*

Consent Form for Dental Treatment

Child Eligibility Criteria

Patient Details

Parent/Legal Guardian Details

Medical History

GP Details

Tough Teeth Fluoride Varnish Program

Consent

Child Dental Benefits Schedule

Appointment preference

Save and Complete Later