Healthy Mouths Childcare Program

Healthy Mouths Childcare Dental Program

We are looking forward to visiting your childcare.

Child's First Name (as shown on Medicare card)

Date Of Birth

Child's Last Name (as shown on Medicare card)

Child's Childcare Centre Name, including suburb

Child's Year / Class

Medicare Number

Reference Number

Expiry Date

Parent/Guardian Information

Your First Name

Address

State

Your Last Name

Suburb

Postcode

Contact Number

Relationship to Child

Secondary Contact Number

Child's Medical History

Does your child have any medical conditions? If yes, please list all.

Does your child have any allergies? If yes, please list all.

Is your child taking any medications? Please list all.

Do you have any dental concerns or comments to add?

Child Dental Benefit Scheme | Payment Information

We will provide a full comprehensive dental examinations both intra and extra-oral, dental health screening, customised tooth brushing and dietary advice, scale and polish and fluoride treatment and xrays if necessary.

If your child is eligible for the Medicare Child Dental Benefit Scheme, we will cover the cost of this visit bulk billed through Medicare, at no additional cost to you. Codes we may claim will be an 88011 (exam), 88111 or 88114 (polish or scale and polish), 88121 (fluoride treatment) and/or 88022 (xrays).

If your child is not eligible for the Medicare Child Dental Benefit Scheme, Dental On Demand is happy to offer a significant discount compared to local pricing to your child. We will be in contact if your child is not eligible for the Medicare scheme (CDBS) to organise payment. We will make contact with you if there will be an out of pocket expense for our visit.

Have you received confirmation your child is eligible for the Medicare Child Dental Benefit Scheme? (Please note: not all children are eligible for this scheme)? Leave unchecked if no or unsure.

I understand if my child is eligible for the Medicare Child Dental Benefit Scheme, Dental On Demand Mobile Dentistry will Bulk Bill for treatment provided, and if NOT eligible OR the limit has been reached on the Child Dental Benefit Scheme, I will be personally responsible for the out of pocket expenses of the treatment provided for my child.

Consent

By submitting below you are consenting to Dental On Demand Mobile Dentistry providing any of the necessary preventative treatment which may include a dental examination, scale, polish, X-rays and/fluoride at the appointment.

Thanks for submitting!

Dental On Demand
Mobile Dental Services

Quality Mobile Dentistry

Healthy Mouths Childcare Dental Program