ADF Register a Patient Regional Visits

Register a Patient

Which dental service location are you registering for? *

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

Patient Details

Title

First Name *

Last Name *

Preferred Name *

Date of Birth *

Gender *

Phone Number *

Address *

State *

Postcode *

Health Insurance Details

Does the Patient have Medicare? *

YesNo

Medicare Card Number

Reference Number

Valid To

Does the patient have any private health insurance? (dental cover) *

YesNo

Private Health Fund Name

Emergency Contact

First Name *

Last Name *

Phone Number *

Medical History

Is the patient pregnant? *

YesNo

Currently taking any medication? *

YesNo

Please give detail

Any known allergies? *

YesNo

Please give detail *

Are there any other serious illnesses, adverse reactions to prior dental treatment or any other comments you would like to make? *

YesNo

Please give detail *

When did the patient last visit the dentist? *

Is the patient under the care of the Department of Child Protection (DCP) ?

YesNo

Legal Guardian

First Name *

Last Name *

Phone Number

Mobile Phone Number *

Email Address

Address *

Same as patientDifferent to patient

Would you like to attend your child's appointment?

YesNo

Address *

State *

Postcode *

I consent to receiving any marketing communications from the ADF and partner clinics. *

YesNo

Does the patient have any particular dental concerns/issues? *

YesNo

Please give details *

Confirmation

I *

confirm that I am the *

FatherMotherLegal GuardianSelf-Consenting (if over 16)

of *

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.

Preferred Appointment Day/Time
Please select a day and time range the patient is avaiable to attend the appoinment. We will then contact you to finalise your appointment time.

Day: *

Time: *

Google reCAPTCHA (Please tick this box) *

Patients aged 2 to 17- Important Information

To complete your child's registration, please complete the Child Dental Benefits Scheme form below.

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.

Medicare Number

Patient / legal guardian signature (CDBS) *

Draw signature|Type signatureClear

Patient / legal guardian signature

Patient’s full name *

Full name of person signing (if not the patient)

Date *