Consent Form. A Guardian/Parent needs to fill up the form for eligibility check. CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM 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 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 cost 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. School/Day-care Name * Child Name * First Name Last Name Child Date of Birth * MM DD YYYY Heading Medicare Card Number * Expiry Date * MM DD YYYY Individual reference number * Parent/ Guardian Name * First Name Last Name Phone Number * (###) ### #### Email * If eligible, please provide oral examination/scale/fissure sealants if required Guardian/ Parents Name: * First Name Last Name Guardian/ Parents Name: When did your child last visit the dentist ? * MM DD YYYY In your child last visit to the dentist did he/she suffered from any allergy ? * Did your child suffer from any bleeding during his/her last dental visit? * Information about your child medical history for your dentist use only. * Are you receiving any medical treatment at present? * Yes No Mention Details * Have you had any serious or long standing illness? * Yes No Have you ever been hospitalized? * Yes No Please indicate if you have EVER had any of the following? * None Diabetes Epilepsy Tuberculosis Familial diseases High orl ow blood pressure Details if yes to any of the above: especially in the last three weeks OR Type no If none of the above applies * Any heart complaint/treatment Blood disorders/ bleding disorders Infectious disease (measles/chicken pox), Rheumatic fever or heart valve surgery? * Yes No Should be Mention details for history of any heart issues. * Any nervous system disorder? * Yes No Asthma/bronchitis/Lung conditions * Yes No Any Radiation therapy /chemotherapy ? * Yes No Any Thyroid disease ? * Yes No Any Hepatitis, jaundice or liver disease * Yes No Any treatment for any form of cancer? * Yes No Any transplanted Organ or or bone bone marrow? * Yes No Any kidney conditions ? * Yes No Any other conditions * Yes No Are you child immunisations up to date? * Yes No Any allergies (e.g. latex, penicillin, etc ) * Yes No If any allergies please mention details? * Any current medication? * Yes No Mention details for any medications? * Please add your comments below Thank you!