New PatientExisting patientNot sure

School/ Centre Name

School/ Centre Suburb

Name of child

Exactly as written on medicare card

Child's Date of birth

Address

E-mail

Parent/ guardian Name

Parent/Guardian contact number

Which day does your child attend child care

So we know your child attends the day or we contact you for an appointment

Medicare Card Number

When was the child's last dental visit?

Medical History

Under the Federal Government’s Child Dental Benefit Scheme if you receive Family Tax benefit A, your child will be eligible for the $1026 of funding for dental services every two years and there will be no cost involved. Funding is available for children aged 0 – 17 years of age. If your child is not eligible for treatment under the CDBS, we will contact you and we offer the check up and clean capped at $67.50. If you have private health cover, you may be able to claim part of it back. Please check our FAQs page for any questions you may have.

Medicare Consent Form

https://www.health.gov.au/resources/publications/cdbs-bulk-billing-patient-consent-form?language=en Please copy and paste the link above in a new browser, download and fill out the medicare consent form, then forward to us via email so that we can check your child's eligibility. Our email address: admin@mobiledentistryservices.com.au

Thank you for submitting the register form. 
Please email us the medicare consent form at your earliest convenience.

Registration Form

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