Smiles for Miles

Register a Patient - Smiles for Miles

Which location would you like to attend for your appointment? *

Patient Details

Title

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

Phone Number *

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

Address *

State

Postcode *

Medicare/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

I agree to provide my physical private health card on the day of the visit.

YesNo

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

Is the patient of Aboriginal or Torres Strait Islander descent?

YesNo

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

Authorised Consentee Details

Is the patient self-consenting?

YesNo

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

Title

First Name

Last Name

Relation

Contact Number

Financial Consentee Details

Is the patient a DVA Card holder?

YesNo

*for eligible DVA Gold Card Holders, dental services fees are covered under the department

Card Number

Expiry Date

Who is the person responsible for the payment of the account?ADF will contact the financial consentee prior to providing any services.

State Trustee Reference Number

Name

Relation

Contact NumberADF will contact the financial consentee prior to providing any services.

Invoice (If Applicable)

EmailPost

ADF will send an invoice after dental services are provided if applicable via your preferred means of contact.

Email Address

Same Postal and Residential Address

Postal Address

State

Postcode

Dental Appointment

Will any person/s be attending the dental appointment other than the patient?

YesNo

Please give details

Does the patient have any particular dental concerns/issues?

YesNo

Please give details

Media Consent - I hereby give consent for the use of my child's photo/video material to be utilised by Australian Dental Foundation on media channels which may include Social Media (e.g. Instagram/Facebook page), website and/or print media to promote our oral health services, in accordance with the Australian Privacy Principals, Part 2 - Collection of personal Information.

YesNo

Confirmation

I

confirm that I am the

FatherMotherLegal GuardianStudent (if over 16)

of

I confirm that all the above information is up to date and correct and I hereby consent to a dental exam by the Australian Dental Foundation at the location the team is visiting *

Yes

I also confirm and consent to these additional services: (check all that apply)

X-RaysFluorideTeeth CleaningFissure Seals (protective coating)

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.

First Name

Last Name

Signature

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Important Information

To complete your child's registration for our program, 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 $1,158) 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

About this Program

The Child Dental Benefits Schedule (CDBS) is an Australian Government program that provides access to basic dental services, within a benefit cap, over a relevant two calendar year period. Services that receive a benefit under the CDBS include examinations, cleaning, x-rays, fissure sealing, fillings, root canals, extractions and partial dentures. The full list of services is available in the Dental Benefits Schedule. The Schedule includes an item number, description, benefit amount and applicable restrictions for each service. Services can be provided in a public or private setting. However, benefits are not available for orthodontics, cosmetic dental or any services provided in a hospital.

A child is eligible for the CDBS if they are:
    • 0-17 years old for at least one day that calendar year;
    • Eligible for Medicare; and
    • Receive a payment from Services Australia at least once a year, or have a parent, carer or guardian who receives a payment from Services Australia at least once a year.

Privacy and Consent information

Your personal information is protected by law, including the Privacy Act 1988 and the Australian Privacy Principles (APPs), and is being collected by your Dental Provider on behalf of the Department of Health, Disability and Ageing (the department).for the primary purpose of facilitating basic dental services under the Child Dental Benefits Schedule.
If you do not provide this information services will not be able to be provided to you under the CDBS.

By providing your personal information to your Dental Provider you consent to the department collecting this personal information about you from your Dental Provider.
You can access the department’s APP privacy policy at https://www.health.gov.au/resources/publications/privacypolicy
The department can be contacted by telephone on (02) 6289 1555 or via email at privacy@health.gov.au

The department will not disclose your personal information to any overseas recipients.

Patient's details

Medicare NumberMedicare Card Number

Ref

Select Title:

Given Name *

Family Name *

DOBDate of Birth

I, the patient/parent/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 and the likely cost of this treatment;

• That I will be bulk billed for services under the ChildDental Benefits Schedule;

• There will be no out-of-pocket costs for dental services provided within a public clinic; and

• That benefits for some services may have restrictions, and that the Child Dental Benefits Schedule covers a limited range of dental services.

NB: This form is valid up to 31 December of the calendar year for which it is signed.

Full name (print in BLOCK LETTERS)

Legal guardian signature

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Date

Patient

Parent

Legal Guardian

(tick one only)