Test

CHILD DENTAL BENEFITS SCHEDULE
BULK BILLING PATIENT CONSENT FORM

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.

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.

Dental Records Release Form

Please forward any of the following information that you have: patient notes, x rays, charting, intra oral photos to

New Dentist: Mitchell Dental Group
mitchelldentalgroup@gmail.com

I hereby give you permission to release any Dental records to
the above Dentist.

HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE INDICATE:

THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS FORM AS FULLY AS POSSIBLE

I have completed this questionnaire to the best of my knowledge, and understand that failure to make full disclosure may place MYSELF at undue medical risk. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and check-up reminders.