Sight & Smiles | Consent Forms

Patient Form

Please take a moment to fill out the form.

Child Full Name

Name of School

School Address

Parent/Guardian's Contact Number

Date of Birth

Year/Class

Parent/Guardian's Full Name

Parent/Guardian's Email

Medical Conditions

Medications

Allergies (if any)

Previous dental history

Wants to avail eye check - Bulk billed through Medicare if your child is eligible. Yes/No

Previous eye history

Wants to avail dental check up and clean - Bulk billed through Medicare if your child is eligible for the Child Dental Benefits Schedule (CDBS). Yes/No

*NOTE: If your child does not have an eligible Medicare card, we will contact you prior to the visit to arrange for a private fee.

For an eye test, the discounted private fee is $71.50, and for a dental check up & clean, it is $99.

Parent/Guardian's consent:
By submitting the form, you consent to:

✔ A dental check up, scale, polish, fluoride by Dental On Demand

✔ A comprehensive eye test by Improve Eyes Mobile Optometry

✔ Medicare billing (if eligible) and private fee (if not eligible)

Thanks for submitting!