Dear Parent/Guardian,

The Mobile School Dentist Vans will be conducting dental visits in the coming weeks at our school. Treatment may be BULK BILLED through Medicare Child Dental Benefits Schedule (CDBS) for eligible students.

  • Fill in Form

    For your child to be seen by the School Dentist, please fill and return this form to your school as soon as possible.

  • Medicare Check

    We will check if your child is eligible for Medicare BULK BILLING through CDBS. Not eligible, but still want treatment? – Fill the optional private payment section OR we will be in contact.

  • Our Visit

    Full examination to identify any issues with your child's teeth. Subsequent Clean, Diagnostic Bitewing X-rays and Remineralisation of teeth only if required.

  • Fillings & Seals

    YES! We can do fillings and fissure seals onsite! We will attempt to call you during or after our visit. If you give us consent, we can do further treatment. If we can't get through, we will provide a written treatment plan after our visit.

Service Disclosure Statement
Please read carefully*

MEDICARE
No out of pocket cost to you.

Medicare CDBS Provides BULK BILLING funding of $1000 over 2 calendar years for preventative dental treatment to selected children aged 2-17. More information about CDBS click on the link below:
Human Services

We will check your eligibility before treatment. The Medicare Benefit amounts for each service we may provide are below. This is paid by Medicare, NOT by you.

Upon initial Examination (88011), if your child requires further treatment, the treatment pricing is listed below.
(Pricing is set by the Department of Health, and is deducted from your Medicare balance.)



Item Service Benefit
88011 Comprehensive Oral Examination $52.65
88012 Periodic Oral Examination $43.75
88013 Limited Oral Examination $27.50
88111 Removal of Plaque / Stain $53.80
88114 Removal of Calculus – 1st visit $89.70
88115 Removal of Calculus – 2nd visit $58.35
88121 Topical Remineralisation agents $34.55
88022 Periapical or Bitewing X-ray $30.45

If your child requires further work, we may contact you after an initial examination. If we cannot contact you, these will be treatment planned.


Common further treatment pricing is below for reference:

Item Service Benefit
88161 Tooth Surface/Fissure sealing $46.05
88162 Tooth Surface/Fissure sealing (Additional services) $23.05
88521 Adhesive Restoration - one surface - anterior tooth - direct $115.45
88531 Adhesive Restoration - one surface - posterior tooth - direct $123.30

If your child’s not eligible, you will be contacted with further options.



MEDICAL HISTORY AND CONSENT













Please tick YES if your child has any of the following conditions:

Condition Yes
Asthma / Other Lung Condition
Diabetes: Type 1 or 2
Cardiac Pacemaker
High or Low Blood Pressure
Fainting / Dizziness
Stroke / Heart / Nerve Condition
Epilepsy
Steroid Therapy
Condition Yes
Cancer / Radiation or Chemotherapy
Bone / Joint Replacement / Osteoporosis / Prosthetic Implant
Kidney, Liver or Thyroid problems
Stomach or Digestive problems
Hep. A, B or C
Anaemia or other Blood Disorders
Excessive Bleeding
Contact with HIV or AIDS






  • I give consent for Mobile School Dentist to provide dental treatment to my child, including a Dental Examination and Diagnostic Bitewing X-rays (x2) if they are required.
  • If my child requires a further clean or remineralisation for their teeth, I give further consent for this treatment.
  • I have read and understood the Service Disclosure Statement and BULK BILLING costs. I understand that these costs will be BULK BILLED from my $1000 Medicare CDBS balance.
  • I give consent for my child’s dental information to be securely accessed and stored by Mobile School Dentist staff for administration purposes.

If you would only like an examination, or do not consent to specific treatment, please specify below.



Parent/Guardian Signature:
Please Sign Here