Consent Form.A Guardian/Parent needs to fill up the form for eligibility check. School/Day-care Name * Child Name * First Name Last Name Child Date of Birth Medicare Card Number Expiry Date Individual reference number Parent/ Guardian Name First Name Last Name Phone Number Email * I consent for my child to be seen by Dentist/Therapist Check-up Clean & polish and if required do a fissure sealant Guardian/ Parents Name: Any allergies (e.g. latex, penicillin, etc ) YES NO If any allergies please mention details? Any current medication? YES NO Mention details for any medications? If you are currently not receiving family assistance part A please transfer $79 discounted from $199 ( this offer is only for children attending daycare/school) Account name: NSW DENT MOBILE CLINICS Thank you!
