Date of Birth*

Gender* MaleFemaleOther

Do you have a Medicare card?*

YES ( please fill in the details below )NO ( we offer a check-up for only $35 per visit )

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 0-17 years old. The entitlement is capped at $1,052 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, we can offer a check-up for only $35 per visit. If you have Private Health Insurance, we will provide you with an invoice after your $35 payment to claim your refund.

Please tick if your child has or had any of the following medical conditions. If yes, Please provide further information:

ADHDArtificial heart valveAsthma/Breathing difficultiesAutismBleeding disorderChronic conditionsDiabetesEpilepsyHepatitis A,B or CHeart conditionsHigh/Low blood pressureInfectious disease/sKidney conditionsTuberculosisOther

Does your Child have any Allergies?*

YES (Please provide more information below)NO

Is your child currently taking any medications?*

YES (Please provide more information below)NO

Are there any main dental concerns for your child?*

YES (Please provide more information below)NO

Social Media / Marketing Consent

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

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 classroom to attend the check-up session with a member of staff, I understand that by completing this form, I give McKinnon Dental Care permission to see my child for one dental check-up visit.

Parent/Guardian Signature*