Dental Paediatrix | Patient Health Questionnaire |

Child Details

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Gender(Required)

Address (no PO Box)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child lives with:(Required)

Do you require an interpreter?(Required)

Yes

Please specify what language.(Required)

Are you of Aboriginal or Torres Strait Islander origin?(Required)

Parent/Guardians Details

Parent/Guardian's Name(Required)

First Last

Relationship to child(Required)

Parent/Guardian's Phone(Required)

Parent/Guardian's Email(Required)

Second Parent/Guardian's Name

First Last

Relationship to child

Parent/Guardian's Phone

Parent/Guardian's Email

Medicare Information

Do you have Medicare?(Required)

Yes

Medicare Number

Child's Reference Number

Expiry:

Private Health Insurance

Do you have Private Health Insurance(Required)

Yes

Health Fund

Member Number

Reference Number

Do you have Private Health Dental Cover?

Yes

Do you have Private Health Hospital Cover?

Yes

Child Dental Benefits Scheme

Do you have Child Dental Benefits Scheme (CDBS)(Required)

Yes

Unsure

Concession Card(Required)

HCC

PCC

N/A

Card Number

Expiry

Medical History

Medical History(Required)

Please list the allergies the patient has(Required)

Medical History (Other)(Required)

If you selected 'Other', please specify.

Medications

Additional Information

In the last 2 years my child's dental / medical visits have been:

Referrals

How were you referred to us?(Required)

Name

First Last

If you chose 'Dentist', 'Doctor' or 'Friend / Relative', please provide us with their name.

Terms and Conditions

Dental Paediatrix respects your right to privacy and considers all of the information you have provided in this form to be personal information.

To the best of my knowledge have provided accurate information relating to my child's health, and if any changes occur will notify the Dentist/Surgery as soon as is practicable.

I acknowledge that my child's records may be sent to their referring doctor/dentist/health professionals involved in their care.

We require total payment after each appointment. We provide a range of ways to pay for your child's dental care including cash, credit and debit card facilities.
We request that no photos or videos takes place within the surgery at any time. Please ask the permission of the operator should you wish to take a photograph.

Please let us know if you have received a letter from Medicare regarding the eligibility of Child Dental Benefits Scheme. Please note we are not a bulk billing practice.

In the very unlikely event of an emergency where an ambulance service is required, the patient/family is liable for the cost.

As a courtesy, we ask our patients to give us at least 24 hours notice to cancel or reschedule the appointments.

I have read and understood the terms and conditions above.(Required)

I have read and understood the terms and conditions below.

Patient Photo Release

I authorise Dental Paediatrix to take photographs, slides and videos of my child/children’s teeth, jaws, and face. I understand that the photographs, slides and videos will be used as a record of my care, and may be used for communication with other health care professionals, educational publications (dental journals), and educational lectures.
I further understand that if the photographs, slides and videos are used in any publication or as a part of a demonstration, my identifying information (first name only) could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs. If I wish to revoke this consent, I may do so in writing.

I have read and understood the terms and conditions above.(Required)

I do not mind if my photographs are used in any of the above stated situations.

I only agree to have my teeth shown without any identifying features.

Signature

Name(Required)

First Last

Date(Required)

Patient Health Questionnaire

Patient Health Questionnaire

Child Details

Parent/Guardians Details

Medicare Information

Private Health Insurance

Child Dental Benefits Scheme

Medical History

Referrals

Terms and Conditions

Patient Photo Release

CONTACT DETAILS

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