Tough Teeth Fluoride Varnish Program Consent

We are offering students a free oral health screening at your child's school.

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.

Please note :

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

Please have your Medicare card ready

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

Patient Details

Medicare Card: *

Individual Reference no. (IRN): *

Expiry date: *

Pension Concession Card / Health Care Card:

Expiry Date:

Title: *

Last Name: *

Given Name(s): *

Date of Birth: *

Gender: *

Street Address: *

Suburb: *

Post code: *

State: *

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:

EnglishOther

Other language:

Child school: *

Grade: *

Class: *

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

Yes (If yes, please provide details)No

Contact persons name and contact number: *

Authority to care document

Browse

Parent/Legal Guardian Details

Parent/Legal Guardian First Name: *

Parent/legal Guardian Last Name: *

Relationship to child: *

Phone: *

Email Address: *

Medical History

Does your child have any of the following medical conditions? *

Allergies eg. penicillin, local anaesthetic, chlorhexidineMedications any tablets/injections/supplements taken by your childAsthma OtherNone of the above

Has your child ever been hospitalised for Asthma?

YesNo

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:

Consent

I, the parent/legal guardian, *

Give consent for patient *

To receive:

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

Patient / legal guardian signature *

Clear

Full name of person signing (if not patient) *

Date 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.
*

Compliant: *

YesNo

Compliant date: *

Fluoride varnish applied *

YesNo

Type of FVP applied? *

DuraphatClinproOther

Visible concerns? *

YesNo

Urgent treatment required? *

YesNoexamination required.

Saliva pH:

GreenYellow

Other:

Results of the FVP: *

Email 1 - urgent dental treatment is neededEmail 2 - follow-up dental treatment is requiredEmail 3 - no visible concerns were noted

How many Operators?

One Two

Operator One *

Operator Two

3 Cs Verification Checklist

Identify the patientInformed consentFinal team check

3 Cs Verification Checklist

Identify the patientInformed consentFinal team check

Name: *

Date: *

Draw signature|Type signatureClear

Signature:

Draw signature|Type signatureClear

Item codes:

010121047141

Item codes:

010121047141