Patient History and Consent
Koo Wee Rup Dental Mobile

Please complete this form accurately to assist us to update your details

Are you eligible to claim Child Dental Benefit Scheme?
Do you have dental Insurance ?

(Number next to patient's name)

Emergency Contact/Person responsible for fees:

Medical History

I have completed the above to the best of my knowledge and understand that failure to make a full disclosure may place my child at undue medical risk. I also understand that I am fully responsible for the financial aspect of my dental treatment.

I hereby give my expressed consent for dental examination and any treatment if required of my child to be carried out on the school premises.

Signature :

(Staff use only)

Australian govt department of health


I, the patient / legal guardians, certify that I have been informed:

  • of the treatment that has been or will be provided from this date under the Child Dental Benefit Schedule,
  • of the likely cost of this treatment ; and
  • that I will be bulk billed for services under the Child Dental Benefit 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 cap.

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.

Full name of person signing the form
(if not the patient)