Aged Care Dental Expression of Interest form

Dental On Demand provides mobile dental services to Aged Care Facilities, homes and independent living houses. Please fill in the below form to express your interest in a dental visit for your loved one. Our friendly staff will be in touch with more information.

Patient's first name

Patient's last name

Patient's Date of Birth

Patient's Gender

Facility Name

Facility Address

Your Contact Email

We will send an intake form for more information, including your invoice and report to this email.

Your Phone Number

Are you the Power of Attorney or Legal Guardian for the resident?:

Is the patient experiencing any urgent or serious dental issues that need immediate attention?

CONSENT [Tick box yes / no]

Before selecting, please review pricing and more information here.

YES, I give consent for both pricing and treatment.

NO, I do not give consent.

By submitting this form, you acknowledge and consent to Dental on Demand collecting your/the patient's personal and health information in accordance with the Privacy Act 1988.

Your information is stored securely and used only for the purpose of providing dental treatment, administrative communication, billing, and appointment recalls. You confirm that you are authorised to provide this information and consent to us contacting you regarding your care.

If you choose to upload photos or clinical images, you consent to Dental on Demand using these images for triage, assessment, and treatment planning purposes only. All images are kept confidential, securely stored, and will never be shared publicly or used for marketing without your separate written consent.

For further information, please refer to our Privacy Policy.

Need further assistance? Please check our FAQs here.

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Aged Care Dental Expression of Interest form