FORMS

Gender *

Female

Male

Other

Parent/Guardian 1 Name *

Mothers Name

First Name

Last Name

Parent/Guardian 2 Name - If not applicable, please write NA *

Name

First Name

Last Name

Do you have health insurance? *

Yes

No

Do you have dental cover?

Yes

No

Do you have hospital cover?

Yes

No

Are you eligible for Medicare's $1000 Child Dental Benefit Scheme?

A child can get CDBS when: - they are eligible for Medicare - they are between 2 and 17 years old for at least 1 day that year. - a parent or child get an eligible payment at least once that year from centrelink PLEASE BE AWARE WE DO NOT BULK BILL.

Yes

No

Unsure

Did you have any x-rays taken at the dentist? *

Yes

No

Have you ever had any of the following? *

Rheumatic Fever

Excessive Bleeding

Asthma

Epilepsy

Persistent Cough/Bronchitis

Heart Problems

Hepatitis

Sleep Apnoea

None of the above

Do have any other conditions? *

(eg Down Syndrome, ADHD, Autism, Developmental or Behavioral issues )

Down Syndrome

ADHD

Autism

ASD

Behavioral Issues

Developmental Issues

Other

None of the above

Do you have any allergies? (e.g. Penicillin, aspirin, latex ) *

Yes

No

Are you presently receiving medical attention? *

Yes

No

Are you presently taking any medication? *

Yes

No

Have you ever been hospitalised? *

Yes

No

Have you ever had a general anaesthetic? *

Yes

No

Have you or anyone in your family had a bad reaction to a general anaesthetic? *

Yes

No