Consent e-form


 

On behalf of  

 

Child Dental Benefits Schedule Bulk Billing Patient Consent

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 funds being available under the benefit cap.

Declaration

  • I understand that I/the patient will only have access to dental benefits of up to the benefit cap;
  • I understand that benefits for some services may have restrictions and that 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 benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.

Leave this empty:

Signature arrow
Signature Certificate
Document name: Consent e-form
lock iconUnique Document ID: 356f43ea299160fc95e8dca73fe07b336fe8e80f
Timestamp Audit
October 13, 2020 12:55 pm AESTConsent e-form Uploaded by Celina Claridge - celina.claridge@totallysmiles.com.au IP 158.140.192.192