Child Consent Form "*" indicates required fields Step 1 of 3 - Child's Information 33% Child's Information:Name* First Last Date of Birth* DD slash MM slash YYYY Gender*GenderMaleFemaleSchool/Center name*Grade*Parent/Guardian Name*Contact number*Email* Address* Street Address City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Medicare Card number*Expiry Date* DD slash MM slash YYYY Child Reference number* Medical History:Is your child receiving any medical treatment*Does your child have any allergies*Please indicate if your child has/had any of the following medical conditions. If any are ticked, please supply further information. Asthma ADHD,OCD,Autism Heart conditions Infection diseases Bleeding Disorder/ Blood Disease. Growth Disorder Lung Disease/Tuberculosis High/Low Blood Pressure Epilepsy Diabetes Kidney Conditions Hepatitis A,B, or C Please list any other medical conditions/ Medications Consent & Signature:Please tick if applicable* I give consent to allow Roaming Smiles to conduct a Medicare Child Dental Benefits scheme eligibility check for my Child*Check Child Dental Benefits If eligible through Medicare Child Dental Benefits Schedule ,i give consent for my child to have a dental check up, scale, clean & remineralising treatment carried out by Roaming Smiles. These services are bulk-billed under Medicare, so no out-of-pocket payment is required. With financial consent, $154.4 can be claimed from your child's CDBS benefits, and fissure sealants, if necessary, can also be claimed from CDBS for $50.45 per tooth.If not eligible If not eligible for benefits under CDBS, I consent to my child receiving a dental check up, cleaning ,scaling and remineralising treatment. This will be provided at a discounted price of $ 79 for kids at childcare centres. If fissure sealants are needed, the dental practitioner will contact you for consent. Our Admin team will send you a secure payment link via SMS or email to settle the account 1 or 2 days prior to the dental visit. If your child fail to attend the appointment for any reason ,full refund will be issued. An Itemised invoice will be sent to you within a week after the dental visit for you to claim from your health fund if you are covered.This field is hidden when viewing the formI, the patient / legal guardian, declare that* I have answered all questions in this questionnaire truthfully and to the fullest extent of my knowledge. I willingly provide my consent for Roaming Smiles to perform dental check-up, scale, clean, remineralising treatment, and fissure sealants (if deemed necessary) to my child. I understand the estimated cost of this treatment. I understand that while I may not be physically present during the treatment, a STAFF member from the Childcare Centres/School will be in attendance. I, the patient / legal guardian, declare that I have answered all questions in this questionnaire truthfully and to the fullest extent of my knowledge. I willingly provide my consent for Roaming Smiles to perform dental check-up, scale, clean, remineralising treatment, and fissure sealants (if deemed necessary) to my child. I understand the estimated cost of this treatment. I understand that while I may not be physically present during the treatment, a STAFF member from the Childcare Centres/School will be in attendance. Consenting Parent Name*Signature*NameThis field is for validation purposes and should be left unchanged.
