Student Details Form

Watagan Dental at School - Student Form

Please complete this form to help us provide the best care for you. If the student is unable to complete this form, a next of kin or legal guardian may fill it out on their behalf.

Student Information

First name

Last name

Birthday

Month

Day

Year

Student School Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Are you in a health fund?

Yes

Name of fund

Medicare card number

Position on card:

Parent/Guardian Contact Information

First name

Last name

Relationship to the cihld?

Best Contact Number

Email address

How did you hear about us?

Student Dental History

Have you visited a dentist before?

Yes

How long since your last dental appointment?

less than 6 months

6 to 12 months

1 to 2 years

longer than 2 years

Do you have any current or past dental issues? (e.g., tooth pain, sensitivity, gum disease)

Are you currently experiencing any dental pain or discomfort?

Yes

Don't Know

If yes please describe

Have you had any adverse reactions to dental treatments in the past? (e.g., reactions to anesthesia, excessive bleeding)

Medical Screening

My child has an allergy

Yes

Don't Know

My child has a medical condition

Yes

Don't Know

My child requires regular medication

Yes

Don't Know

My child has a disability

Yes

Don't Know

If you answered yes to any of the above, please describe.

Name of Doctor (GP)

Location

Medical Photography Consent

In certain circumstances, photography may be taken as part of your consultation to monitor and assist in managing conditions. These images will form part of your medical record.

I consent to photographs being taken, stored in my dental record.

Yes

I consent to my photographs being de-identified and used for medical education, teaching, or research purposes, including publication in medical journals.

Yes

I consent to my de-identified photographs being used for website or publicity purposes.

Yes

Student Treatment Consent

I consent to my child having a dental check up

Yes

I consent to my child having dental x-rays (if required)

Yes

I consent to my child having a dental clean (if required)

Yes

I consent to my child having fissure seals (if required)

Yes

I consent to my child having fluoride varnish (if required)

Yes

Do you wish to attend your childs appointment?

Yes

Consent For The Use Of An Electronic Scribe

At Watagan Dental, we strive to provide you with exceptional care. To streamline our school visits we use a secure note-taking tool to accurately document our discussions and the outcomes of your appointments for our dental record. No recordings are kept of these conversations.

I understand that an electronic scribe will be used during the appointment.

Yes

No - we cannot see your child

Cancellation Policy

To ensure all patients have an opportunity to get the treatment they need we require 24 hours notice of appointment cancellation. Canceling with less notice than this will incur a fee. Please see our cancellation policy at: https://www.watagandental.com.au/services/cancellation-policy

I have read and understood the information provided about the Watagan Dental Mobile Dental Program.
I understand that I can withdraw consent at any time. To do this, give us a quick call on 02 4977 1222
I have had an opportunity to ask questions and seek clarification on the information I have been provided by calling 02 4977 1222 by visiting the website www.watagandental.com.au
I understand that a Watagan Dental representative may contact me to clarify any of the information provided in this form and/or to discuss my child’s oral health.
I declare to the best of my knowledge that I have provided accurate information about my child including any medical conditions which may affect dental treatment

We are here to help. Check this box to receive emails with appointment reminders, mobile service updates, upcoming school visit information and helpful oral health tips. Unsubscribe anytime.

Signature

I confirm that the information provided is accurate to the best of my knowledge. I give consent for my child to have the treatment that I have ticked in this document to be performed at their school dental visit.

Date

Month

Day

Year

Name of person signing if different from parent/guardian listed in this form.

Relationship to student if the person signing if different from parent/guardian listed in this form.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.