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Chermside EEC Dental Visit

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Chermside Family Dental attending Chermside Early Education Centre

Dear Parent/Guardian

This is the medical and general consent form that allows Chermside Family Dental to provide dental care to your child at Chermside Early Education Centre.

The treatment will include a dental examination (check-up), clean and remineralising application (calcium treatment), if necessary.

The service is bulk-billed for eligible families under the Medicare Child Dental Benefits Scheme (CDBS). CDBS provides eligible children aged 0-17 years with $1132 funding for dental care, every two years. If you receive Family Tax Benefit A then you are likely eligible. Chermside Family Dental will also confirm your child’s eligibility.

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If your child is not eligible for CDBS, Chermside Family Dental will contact you to advise you. We can provide treatment for your child at a private fee, which you may claim through your health fund. We are preferred providers for Medibank Private, BUPA, NIB and HCF.

Having this service at Chermside EEC, in a familiar environment, makes your child comfortable and gives them a positive dental experience, with the company of their peers.

After their visit, Chermside Family Dental will email you a Dental Report and invoice. We will advise if your child requires further dental care.

We highly recommend this program as maintaining your child’s dental and oral health is extremely important to us.

If you require any further information, please feel free to contact Chermside Family Dental on 33503530 or by the Contact Us on our website. Our email is reception@chermsidefamilydental.com.au

It is important for us to know details about your child’s medical history as these could affect the success of your child’s dental treatment. Please fill out this form accurately. The information you provide is confidential and will be handles in accordance with our privacy policy. We can provide a copy of this to you on request.

Firstly, please complete the general patient registration form on our website:

www.chermsidefamilydental.com.au/registration/

Then, please complete the below information:

Mandatory Consent:

I consent to Chermside Family Dental conducting a CDBS Medicare eligibility check for my child. If eligible for CDBS, please provide my child with an oral examination, clean and remineralisation agent application (Tooth Mousse), if possible. I understand that it is the childcare centre’s responsibility to correctly identify my child for the servicing dental practitioner.

If my child is not eligible, I consent to being contacted by SMS/email or phone call to organise prepayment of up to $109 for the visit. You can then claim this through your health fund, if applicable. If you are part of Medibank Private, BUPA, HCF or NIB please advise us so that we can utilise the appropriate fee for your claim.

I consent to Chermside Family Dental emailing my invoice and child’s dental report following the dental visit. Please ensure you have filled out your email address clearly on the medical history form.

I also consent to being contacted by SMS or phone call to organise my child's visit.

Please choose one of the following.
Please note that you will receive a detailed report to your email whether you are present for the appointment or not:

I consent to Chermside Family Dental taking photos of my child during dental treatment, and to these photos being posted on Chermside Family Dental Social Media (Facebook and Instagram @chermsidefamilydental).

CDBS consent form: please complete this if you believe you are eligible

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM

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

I understand that I/the patient will only have access to dental benefits of up to the benefit сар.

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.