School dental appointment form

Only complete if your child is enrolled at a school where a dental van/clinic is currently located.

Once the form has been submitted successfully, a confirmation message will be displayed and you will receive a confirmation email if you have entered a valid email address.

Wide Bay Oral Health Service will then contact you for an examination / check up appointment for your child / children.

Note - a parent/legal guardian must attend with your child at the first appointment.
(Step parents and grandparents can not sign at this 1st appointment unless they are the legal guardian.)

If more than 3 children please do another application for other children.

Required fields are marked with an asterisk (*).

Guardian Details

First name *

Surname *

Preferred Contact number *

Alternative Contact number *

Email *

Are you happy to receive appointment information by text message? *

Preferred contact method *

Street Address *

City/Town *

State *

Postal Code *

Medicare Details - First Child

Medicare card number

Medicare card expiry (enter 01 for dd)

Medicare card line number

Given name(s)

Surname

Is the child known by any other name? Preferred name

Date of Birth

Gender

Is your child of Aboriginal, Torres Strait Islander or South Sea Islander origin

Language spoken at home

Country of birth

Is the child eligible for the Child Dental Benefits Scheme (CDBS)

Are we able to check your child's CDBS balance and access this funding to pay for treatment through Medicare?

School

Grade

Guardian's relationship to child (eg. Parent/Guardian/Foster Parent)

Has the child previously seen a dentist?

Medicare Details - Second Child

Medicare card number

Medicare card expiry (enter 01 for dd)

Medicare card line number

Given name(s)

Surname

Is the child known by any other name? Preferred name

Date of Birth

Gender

Is your child of Aboriginal, Torres Strait Islander or South Sea Islander origin

Language spoken at home

Country of birth

Is the child eligible for the Child Dental Benefits Scheme (CDBS)

Are we able to check your child's CDBS balance and access this funding to pay for treatment through Medicare?

School

Grade

Guardian's relationship to child (eg. Parent/Guardian/Foster Parent)

Has the child previously seen a dentist?

Medicare Details - Third Child

Medicare card number

Medicare card expiry (enter 01 for dd)

Medicare card line number

Given name(s)

Surname

Is the child known by any other name? Preferred name

Date of Birth

Gender

Is your child of Aboriginal, Torres Strait Islander or South Sea Islander origin

Language spoken at home

Country of birth

Is the child eligible for the Child Dental Benefits Scheme (CDBS)

Are we able to check your child's CDBS balance and access this funding to pay for treatment through Medicare?

School

Grade

Guardian's relationship to child (eg. Parent/Guardian/Foster Parent)

Has the child previously seen a dentist?

Privacy

Disclaimer *

I hereby accept and agree to abide by the terms and conditions as stated below and I acknowledge that I have read and understood the Wide Bay Hospital and Health Service's Privacy Satement and Disclaimer

PRIVACY STATEMENT: Personal information provided in Email correspondence sent to this site will be collected and retained in accordance with the provisions of the Hospital and Health Boards Act 2011, the Right to Information Act 2009 and Information Privacy Act 2009. Any enquiries forwarded to this site will also be treated as a public record and retained as required by the provisions of the Public Records Act 2002 and other relevant Acts or regulations.

We will not add any details (including personal details) from your email to any mailing list, unless authorised, and we will not disclose these details to third parties without your express written consent, unless required or permitted by another Act or law.
For a full copy of our privacy policy, click here

DISCLAIMER:

While Wide Bay Hospital and Health Service endeavours to ensure that the online transmission of the form, containing your information, over the internet is secure, the inherent nature of the internet means that there is a potential risk that your information may be viewed or intercepted by third parties. Accordingly, submission through the online form shall be at your own risk and Queensland Health accepts no responsibility or liability for any unauthorised access to your information contained in the form when it is submitted online over the internet. Individuals who submit the form online should receive an acknowledgement from Wide Bay Hospital and Health Service that the Form has been sent, on the screen, following submission. Wide Bay Hospital and Health Service accepts no responsibility or liability if this acknowledgement does not appear or we do not receive your online submission.

You acknowledge that you have read and understood Wide Bay Hospital and Health Service’s Privacy Statement and Disclaimer.

Last updated: 17 March 2020

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School dental appointment form