Enrolment Form

Dear Parent/Guardian,

The Dental Van is a service provided by “Goldfields Teeth Express” - Goldfields Family Dental and is staffed by dental practitioners registered with the Dental Board of Australia

There is a strong emphasis on prevention, oral health education and early intervention. You are welcome to visit the Goldfields Teeth Express to discuss your child's dental care.

Enrolling your child for the Dental Van grants us permission to collect your child from their classroom to perform an oral examination or 'dental check-up', dental radiographs and photographs, scale and cleans and fluoride on your child. These treatments occur periodically. If we determine further dental care is required, we will seek additional consent from you. If your child has an appointment booked in advance, it is your responsibility to transport your child to the Dental Van, unless they are on school grounds we will collect them from the classroom.

For those eligible, the cost of the treatment can be claimed under the Medicare Child Dental Benefits Schedule. The account will be bulked billed to Medicare up to a limit of $1,095. If the cost of treatment exceeds this amount, you will be informed prior to any treatment being completed.

For those who are not eligible, payment can be taken on the Dental Van. Private health can be claimed on the day, otherwise a receipt will be provided to claim directly with your insurer.

To enroll your child for the Goldfields Teeth Express, Dental Van. Please submit this form.

Yours sincerely,

“Goldfields Teeth Express”
Goldfields Family Dental

Please complete the following section so that Goldfields Family Dental is able to identify your child.

DETAILS OF CHILD:
Name(Required)
MM slash DD slash YYYY
Is the child of Aboriginal or Torra Straight origin? Please select one of the following.(Required)
Is this a child care centre? Please select one of the following.(Required)
CONTACT DETAILS OF PARENT/GUARDIAN
Name(Required)
(Required)
REGISTRATION

Please sign below to register your child for the School Dental Service.

I consent to the dental examination, dental radiographs, photographs, scale and cleans and fluoride of my child. I understand that further consent will be sought prior to the commencement of any planned course of treatment. I also understand my financial responsibility attached to associated appointments and consent to payment of these appointments.

MM slash DD slash YYYY
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