School Student Consent Form
Please tick if you agree to the following:
Please sign below if you consent to us providing the above mentioned services.
I am the parent / guardian / person financially responsible (please circle)
Medical History Questionnaire
Please provide details or discuss them with your dentist. Information about your medical history is for your dentist’s use only.
Please indicate if you have EVER had any of the following:
CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM
• 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 of up to the benefit cap.
I understand that benefits for some services may have restrictions and that 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 benefits are exhausted.
This form is valid up to 31 December of the calendar year for which it is signed
I agree that the above is a true and accurate record. I further agree that this form is a guide only and that I should discuss any relevant matters with our dentist prior to the commencement of any dental treatments. By ticking this box, I consent to my child to receiving part or all of aforementioned treatments as recommended by the dentist.
Payment OptionsPlease tick your preferred payment option:
Pay via direct deposit
Pay via PayPalTo pay via PayPal, download the PayPal app or log onto the PayPal website. When asked, our email address is firstname.lastname@example.org. Follow the prompts from there to pay $99 for the service.