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Ausmile Mobile Dental Care

Parental Consent - Medical & Dental History

Dental History

1. When was your child's last dental visit?

Yes Never

If yes, Date:

2. Did your child have any dental complications/issues (e.g., excessive bleeding during dental treatment) during the last dental visit?

Yes No

Your Child's Details

First Name*

Last Name*

Date of Birth*

Medicare Card Details

Medicare Card No (10 digits)*

Reference Number (IRN)*

Expiry Date*

Parent/Guardian Details

First and Last Name*

Phone Number*

Home Address*

Medical History

Does your child have a serious medical condition?

YES NO

Does your child require taking regular medication?

YES NO

Does your child have any allergies?

YES NO

If your child is not eligible under Medicare, would you like to pay out of pocket?

YES NO

General Consent

I consent my child to receive the following: Dental examinations, necessary preventive oral care (exam, clean, polish) and application of tooth mousse/fluoride and fissure sealants application if required.*