Register a Patient

We will send email confirmation with a copy of this completed form for your records.

Register a Patient - Aged Care

Register a Patient - My School Dentist

Facility Details

To prevent a delay in booking a dental appointment, a copy of the patients medication charts and diagnosis summary (including surgical history) must be provided by the facility 3 days prior to scheduled dental visit.

Patient Details

Medicare/Health Insurance Details

Emergency Contact

Medical History

Legal Guardian

Authorised Consentee Details

ADF will contact the facility and the authorised consentee to inform them of the patient’s appointment time and date.

Who is the person responsible for making medical decisions on behalf of the patient?

Financial Consentee Details

*for eligible DVA Gold Card Holders, dental services fees are covered under the department
ADF will contact the financial consentee prior to providing any services.
ADF will contact the financial consentee prior to providing any services.
ADF will send an invoice after dental services are provided via your preferred means of contact.

Dental Appointment


Confirmation

I hereby consent to the Australian Dental Foundation collecting relevant information to assist in the provision of dental care and to provide the dental treatment required during the upcoming dental appointment. 

I agree that the information I have provided above is true and accurate, and I understand that failure to pay this account in full by the due date may incur additional costs, fees, and charges to recover the outstanding amount. I further acknowledge that failure to cancel an appointment without any fair notice may also result in a charge applied. I understand if additional treatment is required, the Australian Dental Foundation’s treating clinician will discuss it with the patient (if self-consenting), and/or with their next of kin/legal guardian before proceeding.


Important information

If any further treatment is required, we will contact you to discuss available options and obtain consent before performing any additional dental treatment. If additional treatment is required, the Australian Dental Foundation’s treating clinician will discuss it with the patient (if self-consenting)/next of kin/legal guardian before proceeding.

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My School Dentist - Important Information

If you are registering a patient for My School Dentist, please also make sure to complete the Child Dental Benefits Scheme form below as well.

The Child Dental Benefits Schedule (CDBS) is a dental benefits program that provides eligible children with financial assistance (capped at $1,095) per child for basic dental services over a 2-year calendar period. Our team will check your child’s eligibility on your behalf and will be in contact with you shortly to confirm your appointment.


Child Dental Benefits Schedule - Bulk Billing Patient Consent Form

Please fill in the form below.



Patient's Medicare Number
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Patient / legal guardian signature
Patient’s full name
Full name of person signing (if not the patient)