My Child's Medical History & Consent

Student's First Name *

Student's Last Name *

Date of Birth *

Gender

MaleFemaleOther

School Name *

Campus

Year Level *

Form Group/Room

Parent/Guardian's Name

Relationship to the Student

Address (Home)

Email Address

Mobile Number

List any other medical conditions

List any allergies

List any current medications

Privacy and Consent

1 Privacy and Consent

I have read and understood the privacy information on page 4. I acknowledge and agree to how the program will manage student healthcare information.

Parent/Guardian's Signature

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Date

2 Medicare Consent and Dental Treatment Authorisation

I have read and understood the Medicare Bulk Billing section of this form, including the safety and benefits of the dental check-up and preventive care treatments as outlined at www.adhv.com.au/dentaltreatment. I have had an opportunity to ask questions and seek clarification on the information I have been provided by calling ADHV on (03) 9323 9607.
I understand that I DO NOT have to pay these costs and that they will be deducted from my child’s CDBS Medicare balance.
I give consent to ADHV to provide dental treatment to my child including a Comprehensive dental examination (Item 88011). I understand if my child requires a clean (Item 88111 or 88114) and/or remineralisation (fluoride) (Item 88121) for their teeth, I give further consent.

I consent for a Pro-Bono dental screening if applicable.
If required, ADHV may return every six months to provide a dental check (Item 88012 or 88013), professional clean (Item 88115), and remineralisation with fluoride (Item 88121).

Parent/Guardian's Signature

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3 Small Dental X-rays (Item 88022)

Significantly increase the detection of tooth decay and are safe for people of all ages. I give consent to take up to 2 small dental x-rays for diagnosis if they are required.

Parent/Guardian's Signature

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4 Fissure Sealants are a coating/seal that help prevent cavities (Item 88161 & 88162)

I also consent to place seals on my childs teeth (molars) if they are required (up to 8 seals).

Parent/Guardian's Signature

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