Forms

Adult Consent Form, Medical History and Information  

Adult Consent Form

Payment Options
You are welcome to pay at the time of your consultation via cash or credit card. Alternatively please provide your payment details below. No amounts will be debited from your card until after your consultation.
Pay via credit card
Pay via direct deposit
  Pay via PayPal
To pay via PayPal, download the PayPal app or log onto the PayPal website. When asked, our email address is accounts@fcmdental.com.au. Follow the prompts from there to pay $99 for the service.

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:
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.
By ticking this box, I confirm that I have read and agree to your Privacy Statement
Aged Care Consent Form, Medical History and Information  

Aged Care Consent Form

Facility
Patient
Authorised Consentee Details
I hereby consent for Future Care Dental Group to provide the nominated service/s to the patient aforementioned.
I acknowledge that I am financially responsible for the costs involved in providing treatment.
GP Details
Patient Medical History
Dental Services
Please make your selection and return this completed form to the facility as soon as possible

Comprehensive Exam & Clean $169
Oral examination including oral hygiene instructions. Scale, clean and fluoride

Denture examination only $80
Includes assessment of gum health and review of denture fit

Payment Details
Please select if applicable

Card no:

Trustee Name:

Reference no:

Credit Card Details
Payment for treatment is pre-approved by credit card authority
 
Verbal/Phone Consent (Office Use Only)
Should further treatment be recommended by the Dentist, a detailed quote will be forwarded to you for approval. Prosthetics (dentures) will require 50% of the total cost to be prepaid before denture manufacture can commence.

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Child Care Centre- Consent Form, Medical History and Information  

Child Care Centre Consent Form

Medicare Card
Please tick if you agree to the following:
Can my child still be seen if they are not eligible for the free dental service?

YES! Our Dentist can see your child and provide them with an oral examination, clean and fluoride for just $79. We will provide you with a receipt and you can claim on your private health insurance if applicable.

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.
By ticking this box, I confirm that I have read and agree to your Privacy Statement
Payment Options
Please tick your preferred payment option:
  Pay via credit card
  Pay via direct deposit
  Pay via PayPal
To pay via PayPal, download the PayPal app or log onto the PayPal website. When asked, our email address is accounts@fcmdental.com.au. Follow the prompts from there to pay $79 for the service.
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School Student Consent form, Medical History and CDBS Information  

School Student Consent Form

Medicare Card
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.
By ticking this box, I confirm that I have read and agree to your Privacy Statement
Payment Options
Please tick your preferred payment option:
  Pay via credit card
  Pay via direct deposit
  Pay via PayPal
To pay via PayPal, download the PayPal app or log onto the PayPal website. When asked, our email address is accounts@fcmdental.com.au. Follow the prompts from there to pay $99 for the service.
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