Consent Form

Smile Patrol Consent Form: This provides us with your child’s necessary details and past medical history.
Medicare Consent Form: This form enables us to access your child’s Medicare details for optimal treatment.

Step 1 of 6

Consent Form Patient Name(Required)

Student First Name Student Middle Name Student Surname

Date of Birth(Required)

Gender(Required)

Is this a Childcare?(Required)

Yes

Is this an Age Care?

Yes

Name of Childcare

Childcare Name(Required)

Age Care Name(Required)

Childcare Address Details(Required)

Street Address City State / Province / Region Postal Code Country

Age Care Address Details(Required)

Street Address City State / Province / Region Postal Code Country

In Which State is Your School Located?(Required)

School Name (VIC)(Required)

School Name (WA)(Required)

Type Your School Name(Required)

Year Level(Required)

Class Group(Required)

Home Address(Required)

Home Address Address Line 2 Suburb State Postcode

Parent/Guardian

IMPORTANT INFORMATION ABOUT THE CHILD DENTAL BENEFITS SCHEDULE (CDBS): -

The Child Dental Benefits Schedule (CDBS) provides eligible children aged 0-17 years with up to $1,095 in funding for preventive dental treatment every two calendar years. This service is covered by Medicare, meaning you do not have to pay for it. For more details, visit the Services Australia website here: https://www.servicesaustralia.gov.au/who-can-get-child-dental-benefits-schedule?context=22426 or check your child's eligibility and CDBS balance through your Medicare online account at myGov, or by calling 132 011.

Smile Patrol will verify your child's eligibility before treatment. Here are some of the Medicare-covered services we provide:

ITEM	SERVICE	BENEFIT
88011	Comprehensive Oral Examination	$57.65
88012	Periodic Oral Examination	$47.90
88013	Limited Oral Examination	$30.10
88111	Removal of plaque/Stain	$58.90
88114	Removal of calculus -1^st visit	$98.20
88115	Removal of calculus -2^nd visit	$63.85
88121	Topical Remineralisation agents	$37.85
88022	Periapical or Bitewing X-ray	$33.35 each
88161	Tooth/Surface Fissure Sealing (first 4)	$50.45
88162	Tooth/Surface Fissure Sealing (additional)	$25.25

Please note:

Free" services apply only to children eligible for CDBS.
We offer private check-ups for children who are not eligible or do not have access to Medicare.
We can only perform a Medicare eligibility check with your permission, hence the need to complete the online consent form.
Once we check eligibility and find your child is not eligible, we will email you information about the option for a private check-up.
After completing the form, we email a PDF handout that explains what "free" refers to and includes all CDBS eligibility details.

Parent/Guardian Name(Required)

First Name Surname

Relationship(Required)

Email(Required)

Enter Email Confirm Email

Mobile(Required)

Emergency Details

Parent/Guardian Name(Required)

First Name Surname

Relationship(Required)

Emergency Mobile(Required)

Emergency Email(Required)

Dear Parent/Guardian,

If your child does not have access to a Medicare card or is not eligible for the Child Dental Benefits Schedule (CDBS), we still want to provide some great dental care during our visit! 🎈

We are pleased to offer a private check-up package that includes a comprehensive oral examination, plaque removal, tooth remineralisation, and a treatment plan—all for just $154.40 per child! 💖

To get started, please register and make a secure pre-payment.

This link: Smile Patrol Payment Link

Don’t forget to include your child’s name and year level! If you have more than one child, you can use the same link for all payments and just add their details. You’ll receive a Stripe receipt after payment, but please note that this isn’t for private health insurance claims. 📄❌

Just a quick heads-up: we can’t issue a receipt for treatment until your child has been seen by a dental practitioner. If you don’t receive it after the visit, just let us know! If you have Private Health Insurance with Dental Cover, you might be able to claim some costs, so check with your provider. 💰✨

Here are the item codes we claim for your reference:
88011 - Comprehensive Oral Examination 🩺
88111 - Removal of plaque and/or stain 🧼
88121 - Topical application of a remineralisation agent 💧

Once you’ve made the payment, please email: info@smilepatrol.com.au so we can schedule your child’s appointment at your school.

We require prepayment to keep everything running smoothly. If your child is absent or we can’t provide treatment, don’t worry—your payment will be refunded. 💵 😌 If you decide not to have your child seen, no action is needed on your part. We’ll only see children whose parents have registered.

If you have any questions, feel free to reach out at info@smilepatrol.com.au or call us at 0401 365 123. 📧📞

Thank you for considering our services! We can’t wait to help your child shine bright with a healthy smile! 😁🌈

CHILD DENTAL BENEFITS SCHEDULE

BULK BILLING PATIENT CONSENT FORM

I, the patient / legal guardian, certify that I have been informed:(Required)

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 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.

Medicare Details

Patient’s full name (On Medicare)(Required)

Patient’s full name

Patient’s Medicare number(Required)

Number next to name (Individual Reference Number)(Required)

Expiry

Month(Required)

Please enter a number from 1 to 12.

Year(Required)

Full name of person signing(Required)

Full name of person signing

Signature

Signed on September 7, 2024

This form is valid up to 31 December of the calendar year for which it is signed.

Parent/Guardian

Emergency Details

MEDICAL HISTORY

DENTAL HISTORY:

CONSENT FOR DENTAL CARE:

CHILD DENTAL BENEFITS SCHEDULE

BULK BILLING PATIENT CONSENT FORM

Medicare Details