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Child Consent Form

Please read and complete the following form accurately so that we can see your child!

Contact Information

Child's First Name

Last Name

Child's Preferred Name (if different to above)

Date of Birth

Child's Gender

Parent/ Guardian First Name

Last Name

Email

Phone

Street Address

Street Address Line 2

City

State

Postcode

Country

Health Information

Is your child recieving any medical treatment at present?

No

Yes

Details (if yes)

Has your child been hospitalised in the last 12 months?

No

Yes

Details (if yes)

Does your child have a medical condition, illness, or injury?

No

Yes

Details (if yes)

Medical conditions - please select if your child has ever had any of the following:

Anaemia

Asthma/ bronchitis/ lung conditions

Diabetes

Epilepsy

Excessive bleeding/ taking blood thinners

Nervous condition

Kidney disease

High or low blood pressure

Stroke

Heart complaint/ murmur

Heart valce disorder/ cardiac pacemaker

Osteoporosis/ bone disease

Stomach or digestive condition

Hepatitis or other liver disease

Cancer/ cancer treatment

Radiation therapy/ chemotherapy

Rheumatic Fever

Thyroid disease

Other

Any other conditions (ADHD, Autism, Sensory Concerns, Dental Anxiety)

Do your child have any ALLERGIES (e.g. latex, milk protein, strawberries etc):

Does your child take any medication?

Do you have NDIS Funding? *

Yes

No

If yes are you?

NDIS Plan Managed

NDIS Self Managed

What are your main concerns with your childs oral health?

What is your availability for appointments?

Do you have private health insurance?

I declare that the information I’ve provided is accurate & complete

Your Signature

Select a date

Thanks for submitting, our team will be in touch soon!

Building your oral health capacity at home

Email: admin@oralhealthhome.com

Dr Carol Tran | 0415 268 107

Leigh Harrison-Barry | 0415 042 766

We acknowledge the traditional Custodians of the land on which we operate, and pay our respects to their elders past, present and emerging. We respect human rights and preople of diverse genders and sexual orientation are welcomed and supported.

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