Medicare CDBS

Child Dental Benefits Schedule Bulk Billing Patient Consent

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

School Name: *

Patients First Name *

Patients Last Name *

Patients Date of Birth *

Medicare Number *

Individual Reference Number *

Your First Name *

Your Surname *

Email Address *

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.

Has your child's medical history changed within the last 12 months? *

YesNo

Please provide more details in regards to your childs change in medical history *

I hereby give consent for the use of my child’s photo / video material to be utilised by the company for the marketing/social media. *

YesNo

I give Teeth On Wheels permission to do the following treatment(s) on my child if required

Check-up/Exam

Clean/Scale

X-Rays- (Recommended to complete a thorough comprehensive examination)

Fluoride Treatment

Fissure Sealants

Fillings- (If applicable, verbal consent must also be obtained)

Parent/Guardian Signature *

Draw signature|Type signatureClear

Date Signed *

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