E-mail

reception@sdhb.com.au

Phone

(07) 4313 1777
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Little Smiles – Consent Form

Little Smiles – Consent Form

    Child Information

    Childcare Centre Name *

    Childcare Centre address *

    Child Name *

    Date of Birth *

    Gender *

    Home Address *

    Medicare Card Number*

    Parent/Guardian Full Name *

    Parent/Guardian Email Address *

    Parent/Guardian Phone Number *

    Emergency Contact *

    Emergency Contact Phone *

    Please tick if your child has EVER had any of the following conditions. Please tick NONE if otherwise. *

    Does your child have any of the following Down Syndrome, ADHD, Autism, Developmental or Behavioural issues (please list)*

    Is your child receiving any medical treatment at present?

    If yes, please list *

    Does your child snack between meals?*

    How many times a day does your child brush?*

    Have you noticed your child grinding their teeth?*

    Have you noticed your child snoring?*

    Has your child had their tonsils out?*

    Does your child suck a dummy, thumb/finger or comforter?*

    If they have stopped, how long ago?*

    Is the child taking any medications (please list) *

    Does your child have any allergies such as latex, milk protein, peanuts, or other? *

    Please list any oral health concerns? *

    Consent

    I will be attending my child's appointment *

    I consent to photos and videos being taken during education and dental treatment and being published on the website, social media and used in promotions *

    Consent Parent/Guardian Signature *

    Date of Consent *

    Is this child in foster or external care?

    Smile Dental provides a dental comprehensive exam and a remineralisation treatment..

    Your options for payment are:

    1. Fully covered by the Child Dental Benefit Scheme (CDBS). Your child's eligibility is dependent on if you are receiving certain payments from Centrelink.
    The item numbers are 88011 ($59.60) or 88012 ($49.55)- (depending on eligibility), 88111 ($60.90) and 88121 ($39.15).

    You can check your eligibility here:
    https://www.servicesaustralia.gov.au/eligible-payments-for-child-dental-benefits-schedule?context=22426

    2. Pay Privately $75 - PAID UPFRONT
    An itemised receipt will be provided for you to claim after the appointment. If you would like to check your coverage the item numbers are 011 ($60), 121 ($15).

    Please select private payment.

    PLEASE CHECK YOUR ELIGIBILITY THROUGH MEDICARE AS YOU WILL BE REQUIRED TO PAY $75 PRIOR TO CLINICAL SESSION

    Payment

    Payment Options

    Payment *

    The dental report will be sent by the end of the week your child is being seen. If you do not receive it, please email us to let us know as it can sometimes go into your junk mail folder.

    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.