Consent Form.A Guardian/Parent needs to fill up the form for eligibility check. School/Day-care Name * Child Name * First Name Last Name Child Date of Birth Medicare Card Number Expiry Date Individual reference number Parent/ Guardian Name First Name Last Name Phone Number Email * I consent for my child to be seen by Dentist/Therapist Check-up Clean & polish and if required do a fissure sealant Guardian/ Parents Name: When did your child last visit the dentist ? MM DD YYYY In your child last visit to the dentist did he/she suffered from any allergy ? Did your child suffer from any bleeding during his/her last dental visit? Information about your child medical history (for your dentist use only). Past/Current medical conditions Are you receiving any medical treatment at present? YES NO Mention Details Have you had any serious or long standing illness? YES NO Have you ever been hospitalized? YES NO Please indicate if you have EVER had any of the following? Diabetes Epilepsy Tuberculosis Famiial diseases High orlow blood pressure Details if yes to any of the above: especially in the last three weeks Any heart complaint/treatment Blood disorders/ bleding disorders Infectious disease (measles/chicken pox), Rheumatic fever or heart valve surgery? YES NO Mention details for any history of hear details? Any nervous system disorder? YES NO Asthma/bronchitis/Lung conditions YES NO Any Radiation therapy /chemotherapy ? YES NO Any Thyroid disease ? YES NO Any Hepatitis, jaundice or liver disease YES NO Any treatment for any form of cancer? YES NO Any other conditions YES NO Is your child immunizations up to date? YES NO Any allergies (e.g. latex, penicillin, etc ) YES NO If any allergies, please mention details? Any current medication? YES NO Mention details for any medications? Thank you!
