Enrollment 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 do an in class dental screening and 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. This is NOT a free service and there are multiple ways to pay including bulk billing to Medicare depending on eligibility. 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:

CONTACT DETAILS OF PARENT/GUARDIAN

REGISTRATION

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

I consent to the in class dental screening, 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.

Medical History Form

Please complete and return to the school office. Please note that any treatment required cannot be commenced until this form has been completed.

Has your child ever had / Currently have of the following? Please select one.

On the "Other", write down the Details / Medications / Dosage

In signing this form, I acknowledge that this represents an accurate medical history. I will advise “Goldfields Teeth Express” Goldfields Family Dental of any changes to this medical history in the future. I understand that all medical details will be treated with complete professional confidentiality.

Child Dental Benefit Bulk Billing Form

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;f
• of the likely cost of this treatment; and
• That I will be bulk billed for services under the the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.

Financial Consent Form

I, the parent or legal guardian, hereby consent to the following financial arrangements for dental services provided by Goldfields Family Dental:

Treatment Plan:

I understand and agree to the treatment plan proposed which includes a description of the recommended dental procedures, their associated costs, and any potential additional treatments that may be required.

Insurance Information:

I acknowledge that it is my responsibility to provide accurate and up-to-date insurance information. I understand that I am responsible for any deductibles, co-payments, or services not covered by my insurance plan.

Payment Responsibility:

I agree to be financially responsible for all charges incurred for the dental services provided. This includes charges that may exceed the coverage limits of my insurance plan.

Payment Options:

I understand that payment is due at the time of service. Accepted forms of payment include Visa, MasterCard or debit. Options for payment plans are available.

Missed Appointments:

I acknowledge that missed appointments or cancellations with insufficient notice may result in a cancellation fee, as outlined by the dental office's policy.

Authorization:

I authorize the release of any necessary information to my insurance company for the purpose of processing claims.

I have read and understand the terms outlined in this Dental Financial Consent Form. By signing below, I agree to abide by these financial arrangements.