12 Month Re-consent

"*" indicates required fields

1Child Information

2Medicare Details

3Parent Information

4Medical History

5Consent

Child name

First name Last name

Have you or any of your family members travelled to a COVID hotspot or been in contact with anyone known to test positive for COVID in the past 14 days?*

School/Childcare Name*

Please tick all that apply*

I give consent to conduct a Child Dental Benefits Schedule eligibility check

I give consent to a dental assessment, scale, clean & remineralising treatment carried out by Bounce Mobile Dentistry (bulk-billed, NO GAP payable if eligible through Medicare Child Dental Benefits Schedule (CDBS)). If further treatment is required, fissure sealant and X-ray services may be conducted.

If NOT eligible, I give consent to a dental assessment, scale, clean & remineralising treatment carried out by Bounce Mobile Dentistry for a discounted, fixed fee of $99 (for a childcare centre, the fee will be $79). If your child requires further treatment, our clinician will contact you for consent.

I understand the following payment options apply if my child is NOT eligible: Bounce Mobile Dentistry will process private fees 1-2 days prior to your child's visit. If your child is not seen, a full refund will be issued.

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.*

Yes

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

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;
That I will be bulk billed for services under the Child Dental Benefits Schedule if eligible, 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.

I agree that the above is true and accurate information has been given. I understand that all information including all photos will be kept private and confidential which Bounce Mobile Dentistry collect during all stages.

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Initials*

Date*

Phone

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12 Month re-consent

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

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