Emergency Contact/Person responsible for fees:
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.
CHILD DENTAL BENEFITS SCHEDULE
BULK BILLING PATIENT CONSENT FORM
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.