12 Month Re-consent

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1Child Information

2Medicare Details

3Parent Information

4Medical History

5Consent

Phone

This field is for validation purposes and should be left unchanged.

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 $108 (for a childcare centre, the fee will be $88). 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.

Initials*

Date*

12 Month re-consent

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

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