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

What is the Child Dental Benefits Schedule (CDBS)?

With assistance from the Federal Government, Medicare has introduced a Child Dental Benefits Schedule (CDBS) that provides children access to basic dental services from the ages of 2-17 years old. The entitlement is capped at $1,158 per child for every two calendar year period.

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.

If my child is not eligible for the CDBS, how much does it cost?

If your child is not eligible for the CDBS funding, Teeth on Wheels can offer a check-up, clean, X-rays (if Required) and fluoride treatment for only $125 per visit (Payment is required prior to the appointment.). If you have Private Health Insurance, Teeth on Wheels will provide you with an invoice after your $125 payment to claim your rebate.

If my child is not eligible for the CDBS, how much does it cost?

If your child is not eligible for the CDBS funding, Teeth on Wheels can offer a check-up, clean and fluoride treatment for only $99 per visit (Payment is required prior to the appointment.). If you have Private Health Insurance, Teeth on Wheels will provide you with an invoice after your $99 payment to claim your rebate.

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

Known Medical Conditions

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;

• There will be no out-of-pocket costs for dental services provided within a public clinic; and

• That benefits for some services may have restrictions, and that the Child Dental Benefits Schedule covers a limited range of dental services.;

Declaration

• 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.

Check-up/Exam $60.95, Fluoride Treatment $40.05, Clean/Scale $62.30- $103.90, Fissure Sealants $53.35, X-Rays $35.30, Fillings $133.70- $280.50

In accordance with the Australian Privacy Principals, Part 2 - Collection Of Personal Information.

Please note: If you do not wish to have any treatments done, please notify the Customer Service department . If a treatment is not required for your child, we will not do the treatment.

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 which will outline what treatment was completed and if anything further is required. If your child requires anything of urgent matter, you will receive a call.

Declaration- By signing this form I, the patient/legal guardian certify that: 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 give my child permission to leave the facility to attend the Teeth on Wheels mobile dental clinic with a member of staff, I give Teeth on Wheels permission to share this consent form with my child's facility, I understand that by completing this form, I give Teeth on Wheels permission to see my child for 2 visits in this calendar year.