Consent Form

This form must be completed correctly for your child to be seen for their dental check-up. If you need help or would prefer a printed form to complete, please email us and we can send it to you. Our email address is

    Child Details

    Date of Birth*


    Medicare / Private Health and Payment Details

    Do you have a Medicare card?*

    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.

    Parent, Guardian

    Medical History

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

    Does your Child have any Allergies?*

    Is your child currently taking any medications?*

    Are there any main dental concerns for your child?*

    Patient Consent

    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.*


    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*

    181 McKinnon Rd, McKinnon VIC 3204
    03 9957 5199
    Click above to book an
    appointment at DentiCare.

    Public Transport
    – By Train: McKinnon Station is located 50 meters away
    – By Bus: Bus 626 travels along McKinnon Road

    Car parking is available at McKinnon Station and behind McKinnon Scout Hall’s building (opposite to our clinic). There is additional parking on McKinnon Rd, Station Ave and Bent St.

    About Us

    We are trusted by hundreds of local families and individuals who want safe, effective, affordable and comfortable dental treatments. It is our mission to provide quality advice that helps you smile brighter.

    Contact Us

    181 McKinnon Rd, McKinnon VIC 3204

    03 9957 5199

    Monday – Friday 8:30am – 5:00pm, Saturday: By Appointment Only, Sunday Closed

    Servicing Suburbs

    We service McKinnon and its neighboring suburbs which includes but not limited to: Glen Huntly, Elsternwick, Brighton, Murrumbeena, Bentleigh, Bentleigh East, St Kilda, St Kilda East, Caulfield East, Caulfield, Caulfield North, Caulfield South, Chadstone, Ormond, Gardenvale, Oakleigh, Oakleigh East, Carnegie, Brighton East, Malvern