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 paediatric 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)

  • Patient’s upper right back teeth

  • Patient’s upper left back teeth

  • Patient’s lower left back teeth

  • Patient’s lower right back teeth

  • Front teeth with lip lifted

Alternatively, 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 x-rays.

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

teledentistry melbourne

Teledentistry Form

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


    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

    First name*
    Surname*

    Address

    Date of birth*

    Have you been to see us before?*

    Preferred method of contact for Teleconsult*


    Parent/Carer details

    Phone number*

    Email*

    Parent or Carer's name 1

    First name*
    Surname*

    Parent or Carer's name 2

    First name
    Surname

    Legal guardian*

    Will any other family members attend this surgery?

    Has a written referral been provided?*


    Private Health Fund
    If you have private health insurance extra cover please provide health fund name.

    Health fund name and Membership number

    Medicare details
    Are you eligible for the child dental benefits scheme?

    Medicare Number

    Patient Reference
    Expiry (mm/yy)

    Health Care or Concession Card
    Do you have a Health Care or Concession Card?


    Medical history
    Name of family doctor

    Has your child had a previous General Anaesthetic?

    Please list any medications your child is currently taking

    Does your child have any allergies, including drugs, medications and latex?

    Is any member of your family allergic to Penicillin?

    Are your child’s immunisations up to date?*

    Please tick the following that apply to your child

    Does your child have any other condition not listed?


    Dental history
    What are your concerns about your child's teeth?
    When was your child's last dental examination?

    Have they had any previous x-rays?*

    Is your child currently experiencing any pain?*

    Did your child have an accident and injure their teeth?*


    Attach photos if able to
    Maximum file size 2MB per upload

    Referral from my dentist

    Photo of area of concern you would like to discuss

    Patient’s upper right back teeth

    Patient’s upper left back teeth

    Patient’s lower right back teeth

    Patient’s lower left back teeth

    Front teeth with lip lifted


    Agreement