Consent Form - Teeth On O'Hea

Paitent Details
Last Name*
First Name*
Date of Birth*
DD slash MM slash YYYY
Contact Phone*
Address*
Suburb*
Email Address*

Private Health Insurance Details
Private Health Fund
Membership Number
Ref #
Medicare Details
Are you completing this form for a child under the age on 18 years old?*
- Yes
- No
Medicare Number
10 Digit Number
Ref #
Single number next to patient name

GP Details
Practice Name
Doctor's Name
Phone
Address
Emergancy Contact Details
Name
Relationship
Phone
Name
Relationship
Phone

Medicare Consent
Patients First Name
Patients Last Name
Medicare Number
10 Digit Number
Individual Reference Number
Single number next to patient name
I, the patient / legal guardian, certify that I have been informed:
- of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule;
- of the likely cost of this treatment; and
- that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.
Declaration
- 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.
Parent/Guardian Signature
Date Signed
DD slash MM slash YYYY
First Name of person signing
Last Name of person signing

Consent
By signing this form I certify that:
• I have completed the form to the best of my knowledge;
• I understand that failure to make a full disclosure may place my child or myself at undue medical risk or compromise their treatment;
• I understand that I am a private patient (if not covered by any scheme or insurance), and understand to pay any necessary fees on the day of treatment.
I understand the Private health insurance claiming policy:
Our No Gap Dental service We provide no-gap dental check up and cleans for individuals who have private health insurance
We accept your payment as a complete payment if covered by your health insurance, providing you fulfill the following conditions
• Availability of valid health insurance with dental extras.
• Annual benefit service expiration has not been exceeded.
• Provide health insurance card on the day of payment.
• Fill out required paperwork provided by Teeth on O’Hea Our Gap Free Service includes
• Initial and regular dental examination.
• X-rays (if necessary).
• Treatment plan (if necessary).
• Professional scaling and cleaning.
• Fluoride treatments.
• Oral cancer screening.
• Intra-oral photos.
• Overall oral healthcare. GAP FREE Dental Service with Teeth on O’Hea
At Teeth on O’Hea, we strive to provide a strong foundation for your lifelong dental health. Our No-Gap dental check-up and clean provides our patients with valid preventative dental at absolutely no extra cost. We encourage all our patients to make regular visits to our dental clinic to receive the most proficient preventative dental. Along with the added value for your money provided by the no gap dental care scheme. Ensure you and your family are on a path to affordable, quality dental care when you need it.
Out of pocket promotions are not applicable to private health insurance. If you wish to access one of our promotions, a full out of pocket payment will be required. Reception will provide a receipt to be able to claim back from your health fund.
Declaration*
- Yes, I have read and understand the information listed above
Signature
Date Signed
DD slash MM slash YYYY
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

This form must be completed correctly for you to be seen If you need help or would prefer a printed form to complete, please email us and we can send it to you.

Step 1 of 6

Paitent Details

Private Health Insurance Details

Medicare Details

GP Details

Emergancy Contact Details

Medical History

Medicare Consent

Consent