School Dental and Childcare 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

Childcare Name(Required)

Childcare Address Details(Required)

Street Address City State / Province / Region Postal Code

In Which State is Your School Located?(Required)

School Name (VIC)(Required)

Please take the time to select your school from the list. It may take a few seconds to load. Selecting the correct school helps us avoid delays in processing your child’s dental care.

School Name (NSW)(Required)

School Name (TAS)(Required)

School Name (SA)(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:

Please note:

"Free" services apply to ALL children regardless of CDBS Eligibility.
We carry out a Child Dental Benefits Scheme (CDBS) & Medicare eligibility check that requires your permission, so you must complete the online consent form in order for us to carry this out.
If your child is not eligible, we will email you the process for your child to be seen for free.
After completing the consent form, we will email a PDF copy for your records.

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)

Does the patient have Medicare?

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 provided or to be provided under the Child Dental Benefits Schedule (CDBS)

of the likely cost of this treatment;

that I will be bulk billed for CDBS services without out-of-pocket costs, subject to available funds under the benefit cap

I understand that:

access to dental benefits is limited to the benefit cap;
some services may have restrictions and CDBS covers a limited range of services;
I am responsible for costs of services not covered by CDBS;
each service will reduce the available benefit cap;
I will need to personally meet costs of additional services once benefits are exhausted.

Consent(Required)

I agree to the assignment of the Medicare benefit directly to the health professional seeing my child.

Privacy Notice: Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the agency, or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the agency will manage your personal information, including our privacy policy.

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 March 12, 2025

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

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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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.