CDBS – Consent Form

CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM
I, the patient /parent / legal guardian, certify that I have been informed:

I understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.

I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.

of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule:
of the likely cost of this treatment; and
that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.
I understand that I / the patient will only have access to dental benefits of up to the benefit

Declaration

I (Parent/Guardian) acknowledge that the above information is accurate and I will advise my dentist of any changes to the above information in the future.

Full name of person signing*

Parent/Legal Guardian signature*

Date*

Getting Here

Smile Dental Hervey Bay is conveniently located in the Madsen Medical Complex at the corner of Urraween Rd and Madsen Rd, directly opposite the Hervey Bay Hospital. Hershel Crt is easily accessible via Madsen Road—no U-turns required. The intersection of Madsen and Urraween Roads is equipped with traffic lights for your convenience.

For pedestrians, a pathway connects the Urraween Road footpath directly to the traffic lights at the hospital corner.

Cycling to Smile Dental Hervey Bay? Bike racks are available at both ends of the complex, and Urraween Road offers excellent bike path connectivity in the Bay area.

Parking is accessible via Hershel Crt, with free on-street and off-street options, including accessible parking spaces located right in front of the breezeway.

Our entrance is through the breezeway, midway along the building. Look for the signage on the roofline of the complex, visible from both Urraween Rd and Hershel Crt. The building exterior is decorated with a distinctive Japanese wave design, and our welcoming reception team are visible through the glass doors.

Our practice is fully wheelchair accessible, with mobility-friendly features, including accessible restrooms situated across the breezeway from our entrance.

Public transport: Bus stops are conveniently located on both sides of Urraween Road, within 100 meters of our practice.

E-mail

Phone

CDBS – Consent Form