CDBS Consent form HCFD - Hoppers Crossing Family Dentist

This form must be completed correctly for your child to be seen for their 2 visits this calendar year.

Patient Details (Your Child)

First Name Of Child

Last Name Of Child

Date Of Birth

Gender

MaleFemaleOther

Does your child attend School or Childcare / Kindergarten?

SchoolChildcare / Kindergarten

Name of the Childcare/Kindergarten/School

Medicare/Private Health and Payment Details

Your medicare number10 digit number

Individual Reference Number(Single number next to patient name)

If you do not have Medicare please enter 12345678901 as medicare number and 1 as Ref number.

What is the Child Dental Benefits Schedule (CDBS)?

You can avail Child Dental Benefits Schedule at our clinic. All children between ages 0 and 17 are eligible to avail the CDBS. It is a program under the Australian Government that lets your child receive general dental services worth $1026 over two consecutive calendar years. Once you receive a confirmation letter from Medicare, you can avail the dental benefits under CDBS.

Am I eligible for CDBS and how do I claim?

To be eligible, you or the child must be claiming one of the following benefits: Family Tax Benefits-Part A, Parenting Payment, Abstudy, Youth Allowance, Carer’s Payment, Disability Support Pension, Special Benefits or Double Orphan Pension. To enquire if your child is eligible, please contact Medicare on 132 011. Once your child’s forms have been completed, we will individually check each child’s eligibility to see if treatment can be bulk billed through Medicare.

How much does it cost in case my child is not eligible?

If your child is NOT ELIGIBLE for the CDBS funding they can still receive treatment. We can offer a comprehensive oral examination and a parent report for $50 or a comprehensive oral examination and a clean (removal of plaque & calculus) and a parent report for $80. If you have private health insurance, we will provide you with a receipt to claim your refund.

Parent/Guardian or Emergency Contact Details

First Name

Last Name

Relationship With Child

Mobile Number

Address

Medical History

Please choose if your child had/has any of the following medical conditions. If you select a condition, please supply any further information.

Other or further information including operations:more details

0 /

Does your child have any allergies?

YesNo

If you chose Yes, please provide details heremore details

0 /

Is your child currently taking any medications?

YesNo

If you chose Yes, please provide details heremore details

0 /

Are there any main dental concerns for your child?

YesNo

If you chose Yes, please provide details heremore details

0 /

Oral Health Status

Diet Analysis

Does your child consume sugary drinks/snacks? (E.g. soft drink, fruit juices, flavoured milk, lollies, biscuits, chocolates etc.)

Less than 1 time daily 1-2 times daily 3+ more times daily

When does your child usually consume sugary drinks and snacks?

Between mealsDuring meals

What is the usual source of drinking water for your child?

TapWell/Tank waterBottled waterOther

Oral Hygiene Behaviour

How many times a day does your child brush their teeth? ehaviour

Less than 1 time daily1 time daily2 times daily3 times or more daily

Does your child have their own toothbrush?

YesNo

Does your child use a toothpaste with fluoride in it?

AlwaysSometimesRarely or never

Does your child brush their teeth before they go to bed at night?

AlwaysUsuallySometimesRarely or no

When was you child's last dental visit?your full name

Social Media/ Marketing Consent

In accordance with the Australian Privacy Principles, Part 2–Collection of Personal Information.I hereby give consent for the use of my child’s photo/video material to be utilised by the company for the purpose of marketing/social media.

YesNo

Treatments

I give permission to Smile For Kids to do the following treatments on my child if required:Please note: If you do not wish to have any treatments done, please call us on 9748 6552. If a treatment is not required for your child, we will not do the treatment.

Check-up/ExamClean/ScaleFluoride TreatmentFissure Sealants

Please note treatment will only be completed if it is required and treatment descriptions are disclosed on our website. After your child’s appointment, you will receive a letter that will outline what treatment was completed and if anything, further is required. If your child requires anything of an urgent matter, you will receive a call.

Please tick the appropriate boxes if you wish to proceed

If ELIGIBLE FOR CDBS, conduct an oral examination ($52.65), Clean -removal of plaque ($53.80) or calculus ($89.70) and application of re-mineralising agent ($34.55) as required. The treatment carried out on the date will be BULK BILLED and covered by CDBS.

If the child is NOT Eligible, do you still wish to proceed with the Dental visit?

YesNo

IF Yes:

If NOT ELIGIBLE FOR CDBS, please provide an oral examination & parent report for a fee of $50 ORIf NOT ELIGIBLE FOR CDBS, please provide an oral examination, removal of plaque/ calculus (clean) & a parent report at a fee of $80

If NOT ELIGIBLE for CDBS and have Private Health Insurance, a receipt will be provided for the option chosen above and can be claimed back from your private health fund depending on the level of your health cover.

Reminder:Would you prefer a courtesy call or SMS text reminder to remind you of your appointment and if required to book a further appointment at Hoppers Crossing Family Dentist?

Courtesy CallSMS reminderBoth

Credit Card Information

Credit Card Type

MasterCardVisaAmerican Express

Card Holder's Nameyour full name

Card Numberyour full name

Expiryyour full name

CVV

Child Dental Benefits Schedule Bulk Billing Patient Consent

I, the patient / legal guardian, certify that I have been informed:Please check all boxes

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; 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.

Declaration

Please check all boxes

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 the 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 the benefits are exhausted.

Check-up/Exam $54.05, Fluoride Treatment $35.45, Clean/Scale $55.20- $92.05, Fissure Sealants $47.25.

Patient's First Name

Patient's Last Name

Medicare Number

Individual Reference Numberyour full name

Parent/Guardian Signature

SignatureI agree to the terms and conditions

(Sign Here)

Clear Signature

Date

First Name of the person signingyour full name

Last Name of the person signing

Patient Consent

By signing this form I, the patient/legal guardian certify that:Please check all boxes

I have completed the form to the best of my knowledge.I understand that failure to make a full disclosure may place my child at undue medical risk or compromise their treatment.I understand that by completing this form, I give permission to Smile For Kids to see my child for 2 visits in this calendar year.

Declaration

Please check this box

Yes, I have read and understand the information listed above

Parent/Guardian Signature

SignatureI agree to the terms and conditions

(Sign Here)

Clear Signature

Dateof appointment