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, $154.00 may be claimed from your child's CDBS benefits

If not eligible for any benefits under the CDBS

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 $89

*Usual check-up and clean at Bright-On Bay Dental is $145.

$89 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
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, 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