Dental treatment & CDBS Bulk Billing Patient Consent Form
*Please return this form to your daycare ASAP or a week prior to our visit.

Dental & Medical Information

Child's Dental habits
  • Brushing teeth
  • flossing
  • grinding
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Medical Conditions

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  • ADHD
  • Asthma
  • Autism
  • Heart Conditions
  • Diabetes
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  • Other (specify)
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Medicare Card (to provide dental services under the CDBS)


Please tick if applicable

  If eligible I consent for my child to receive the following: 

  •  Comprehensive examination 

  •  Clean (scale or prophylaxis treatment as needed)

  •  Preventative fluoride treatment 

Note: This is Bulk-billed under Medicare (You do not need to pay out of pocket). If you give financial consent,

up to $159.65 may be claimed form your child's CDBS benefits.

I consent for my child to receive the same high quality treatment including any of the following: comprehensive examination, clean (Scale or prophylaxis as needed) and preventive fluoride therapy for $109

*Usual check-up and clean at Bright-On Bay Dental is $155.

If not eligible for any benefits under the CDBS. $109 Payment is required before day of treatment.

Payment options:

Bank transfer

  • BSB: 112 879

  • Acc number: 467353441

  • Name: Bright-On Bay Trust

  • Reference: “Child’s name”

  • Please email receipt of the payment to [email protected]

Credit card taken over the phone at our practice number (02) 9538 7028

Credit card via a secure link. Please text 0482 072 487 and write “Payment link for child care visit”

We will email you a receipt of services provided which you can then use this to claim back any benefits from your fund.


 I, The patient/legal guardian, certify that I have been informed: 

  • Of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule 

  • Of the likely cost of this treatment; and 

  • That I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funding available under the benefit cap. 

 

I understand that I/the patient will only have access to dental benefits up to the benefit cap. 

 

I understand that the benefits of some services may have restrictions and that the Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule. 

 

I understand that the cost of services will reduce the available benefits cap and that I will need to personally meet the costs of any additional services once the benefits are exhausted. 

 

Declarations: 

  • I have completed the questionnaire to the best of my knowledge

  • I understand that dental visits conducted at the daycare are limited to basic screenings and may not detect all dental issues. A future visit to the dental clinic is recommended, where equipment at our facility will provide comprehensive care and diagnosis.

  • I, the parent/guardian of the above named child have read-through and understood the treatments provided by Bright-On Bay Dental and give voluntary consent for Bright-On Bay Dental to conduct treatments if deemed appropriate by a registered dental practitioner with or without myself being present. If I am not present on-site, a STAFF member of the facility will be present

Signature

Clear

*Please complete this form a week before our daycare visit. This ensures things are organised & we can check eligibility for your child through Medicare.