Patient Information Form

In response to COVID-19 and the Australian Dental Association Level 3 restriction placed on all dental practices, we are now offering teledentistry consultations for your child.

Once you have submitted the form below if this is deemed as a suitable option we will contact you to arrange for one of our pediatric dentists to phone or video communication (via Zoom) to help answer questions you may have on your child’s dental health.

Before beginning this form, where possible please take 5 photographs on your mobile phone. (Optional, but preferred method of assessment)

  1. Patient’s upper right back teeth
  2. Patient’s upper left back teeth
  3. Patient’s lower left back teeth
  4. Patient’s lower right back teeth
  5. Front teeth with lip lifted

or if you have a dental referral please take a photo of the referral and photos of the areas of dental concern. Also please attach any xrays.

 

Please refer to our HOW TO TAKE TELEDENTAL PHOTOS page to assist you in taking the best possible photos of your child’s teeth.

 

PLEASE NOTE:

After completing and submitting this form our team will assess the information provided and arrange a suitable time to call 

Fee for dental phone consultation service is $100 for up to 30 minutes.

Fee for infant tongue tie phone consultation – $100 (if under 30min) or $150 for 31-45 minutes

Patient Information Form

IMPORTANT

Does your child have a fever, cough, or difficulty breathing* *
Have you or your child been in contact with any suspected or known cases of COVID-19 *

Patient information

Have you been to see us before? *
Address
Address
Suburb
State
Postcode
Country

Parent details

Legal guardian *
Has a written referral been provided? *

Private Health Fund

If you have private health insurance extra cover please provide health fund name

Medicare details

Are you eligible for the child dental benefits scheme

Health Care or Concession Card

Do you have a Health Care or Concession Card?

Medical History

Does your child see a medical specialist regularly?
Has your child had a previous General Anaesthetic?
Are your child’s immunisations up to date? *
Please tick the following that apply to your child

Dental History

Have they had any previous x-rays? *
Is your child currently experiencing any pain? *
Did your child have an accident and injure their teeth? *

Photos Attached if able to

Referral from my dentist
Maximum upload size: 67.11MB
Photo of area of concern I would like to discuss
Maximum upload size: 67.11MB
Patient’s upper right back teeth
Maximum upload size: 67.11MB
Patient’s upper left back teeth
Maximum upload size: 67.11MB
Patient’s lower left back teeth
Maximum upload size: 67.11MB
Patient’s lower right back teeth
Maximum upload size: 67.11MB
Front teeth with lip lifted
Maximum upload size: 67.11MB

Agreement

By submitting this for I acknowledge, to the best of my knowledge, all the preceding answers are true and correct. *