Aged Care Consent Form

Full Form Version 1.2 (Aged Care)

Step 1 of 2

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Name(Required)

Resident' First Name: Last Name

Date of Birth:(Required)

DD slash MM slash YYYY

Facility Name:(Required)

Room Number:(Required)

INITIAL DENTAL CARE PACKAGE

Our Initial Comprehensive Dental Care Package

Comprehensive Examination
Clean and Scale
X-rays
Tooth Remineralisation Application

CONSENT

Can the resident consent for themselves?(Required)

Yes

Resident Consent I,(Required)

consent to receive dental treatment as described above.

I understand that:

The treatment will be provided by a qualified dental professional.
I can ask questions about my treatment at any time.
I can withdraw my consent at any time.
Additional treatments, if required, will be discussed with me before proceeding.
I have read the patient information handout (link).

Signature(Required)

Date(Required)

DD slash MM slash YYYY

Consent on Behalf of Resident

1. Do you have the authority to consent for the resident?(Required)

Yes

2. Your full name:(Required)

3. Your relationship to the resident:(Required)

Medical Power of Attorney

Guardian

Other authorised person (please specify):

Other authorised person (please specify):(Required)

4. Your contact details:

Phone(Required)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State / Province / Region Postcode Country

I(Required)

, consent for the resident to receive dental treatment as described above. I understand the points listed in Section 2A.

Signature(Required)

Date(Required)

DD slash MM slash YYYY

Private Health Insurance

Do you have private health insurance?(Required)

Yes

Insurance Provider Name(Required)

Member Number:(Required)

DVA (Department of Veterans Affairs) INFORMATION

Are you a DVA card holder?(Required)

Yes

Please select your card type:(Required)

Veteran Gold Card

Veteran White Card

Veteran Orange Card

Please provide your DVA File Number (8 digit space only – has letters and numbers)(Required)

Consent for Private Dental Check-Up

Yes

Do you consent to a private dental check-up, which will incur a fee of $300? This comprehensive dental package includes the following services: Examination Scale and Clean X-rays Tooth Remineralisation

If you choose not to consent to the private dental check-up, we regret to inform you that we will be unable to provide any dental care services.

Thank you for your consent! We will arrange to send you a payment link via email. Please note that your treatment appointment can only be scheduled once the payment has been completed prior to your visit. Thank you for your understanding.

MEDICAL HISTORY

Please answer the following questions to the best of your knowledge:

1. Are you currently under the care of a physician?(Required)

Yes

If yes, please explain:

2.Have you been hospitalised in the last 5 years?(Required)

Yes

If yes, please explain:

3. Do you have any allergies?

Yes

If yes, please list:

4. Are you allergic to any medications?

Yes

If yes, please list:

5. Are you currently taking any medications, including over-the-counter drugs?

Yes

If yes, please list:

6. Are you taking any blood thinners (e.g., Warfarin, Aspirin, Plavix)?

Yes

If yes, please list:

7. Do you have or have you ever had any of the following conditions? (Check all that apply)

Heart disease

High blood pressure

Heart valve problems

Artificial heart valve

Heart murmur

Rheumatic fever

Pacemaker

Stroke

Diabetes

Kidney disease

Liver disease

Thyroid disorder

Asthma

Respiratory disease

Tuberculosis

Cancer

Radiation therapy

Chemotherapy

Arthritis

Osteoporosis

Joint replacement

Bleeding disorders

Anaemia

HIV/AIDS

Hepatitis

Epilepsy/Seizures

Mental health disorders

Sleep apnoea

Sinus problems

Acid reflux/GERD

Dementia

Parkinson's disease

Glaucoma

8. Have you ever had endocarditis?

Yes

9. Do you require antibiotic premedication for dental procedures?

Yes

10. Have you ever had complications from dental anaesthesia?

Yes

11. Do you smoke or use tobacco products?

Yes

how much per day?

12. Do you consume alcohol?

Yes

how often?

13. Do you have any difficulty swallowing?

Yes

14. Do you experience dry mouth?

Yes

15. Do you have any mobility issues that might affect dental treatment?

Yes

Please Explain:

16. Is there any other medical condition or information that we should be aware of?(Required)

Yes

Please explain any other medical condition or information that we should be aware of

DENTAL HISTORY

17. Do you have any of the following?

Dentures (Full or Partial)

Dental implants

Bridges

Crowns

Other

Other (please specify):

18. Do you experience any of the following?

Dry mouth

Difficulty swallowing

Jaw pain

Bleeding gums

Tooth sensitivity

Bad breath

19. When was your last dental visit?

20. Do you have any current dental concerns?

I certify that the information provided in this form is complete and accurate to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (the resident's) health. I agree to inform the dental office of any changes in medical status.

Signature (Resident or Authorised Person):

Date

DD slash MM slash YYYY

Get in Touch

Ready to experience the Smile Patrol difference? Contact us today to learn more about how we can bring professional dental care directly to your community. Whether you’re managing a school, an aged care facility, or a childcare centre, we’re here to make dental care easy, fun, and effective.

I am a site or facility

I am a parent or patient

At Smile Patrol, we deliver top-quality dental care wherever you are—at school, in aged care, or at a childcare center. Our mobile services ensure everyone receives the care they need in the comfort of familiar surroundings.

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0401 365 123

info@smilepatrol.com.au

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In the spirit of reconciliation, Smile Patrol acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.