Mia D’Souza

Dear Parents and Carers

If you would like your child to have the opportunity to join the Semper Dental school dental program, please complete this document and submit it via the portal as soon as possible.

The treatment program is available to all participating students in your child’s school for up to two visits subject to our agreement with the school.:

1. Families in receipt of Family Tax Benefit Part A are eligible for the Medicare Child Dental Benefit Scheme Funding. For additional CDBS details please visit: https://www.humanservices.gov.au/individuals/services/medicare/child-dental-benefits-schedule.

2. Ineligible children can be treated for discounted amount of $115.00 which covers all treatments (excluding fissure sealant). If you have private health insurance, you can claim this cost against your private health cover. (see Pages 2 and 4 for additional information and payment options)

The treatment program is offered in accordance with The Australian Dental Association recommendation that all primary school age children should see the dentist every six months. This is important to ensure that your child’s teeth are well maintained, and six-monthly treatment will minimize the chance of decay.

This preventative treatment involves an oral examination and treatment such as scaling, cleaning, fluoride application and fissure seals where necessary. We will provide you with a report on each visit and will inform you if your child requires additional dental care.

If you wish to go ahead, please have the document completed and submitted via this portal as soon as possible.

For more information, please contact Semper Dental directly via email on annap@semperdental.com.au or call Anna on 0422 020 335

School Name: St Mark's Primary School Dingley

Parent/Guardian name: Shiju Mammen
Parent/Guardian contact number: 0402888775
Parent/Guardian email: mammen19@hotmail.com
Child First Name: Mia
Gender: Female
Child Last Name: D’Souza
Date of Birth: 26/03/2020
Your child last visit a dentist: 1 year ago
Grade: Prep
Class: Foundation M
Teacher: Courtney Michaels

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. 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.

I Shiju Mammen the parent / 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; (see over page) 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.

Medicare Card Details

Medicare Number
3425 48224 7

Ref. No.
2

Patient's Name
Mia D’Souza

Valid To: 12/2026

Photo of Medicard

For every one of your visits I give permission for Semper Dental to conduct a Medicare eligibility check for my child and for you to provide preventative treatment which may include oral examination, scaling, clean and polish, removal of deposits (debris and stains) fluoride and fissure seals as required.

Ineligible for Medicare Child Benefits Scheme

Children not eligible for the Medicare Child Dental Benefits Schedule (CDBS) can still attend our school dental visit for a discounted fee of $115, covering all standard treatments (excluding fissure sealants). This may be claimed through private health insurance.

Wished to pay: No

Indicated if your child has EVER had any of the following

Are you receiving any medical treatment at present? If Yes provide details: No
Have you had any serious or long standing illness? If Yes provide detail details: No
Have you been hospitalised? If Yes provide detailsdetail details: No
Are you taking any current medication? If Yes provide details: No
Allergies (e.g. latex, nuts, milk, lactose etc ) If Yes provide details:
List of other allergies not mentioned above:
Do you need to discuss any relevant matters with your dentist prior to the commencement of any dental treatments. If Yes provide details: No

Asthma: No
Kidney conditions: No
Breathing difficulties / Bronchitis / lung disease: No
Any Nervous system disorder disease: No
Rheumatic fever or heart valve surgery: No
High or low blood pressure: No
Blood disorders/ bleeding disorders: No
Hepatitis, jaundice or liver disease: No
Epilepsy: No
Treatment for any form of cancer: No
Diabetes: No
Transplanted organ or bone marrow: No
Familia diseases: No
Thyroid disease: No
Infectious disease (measles, chicken pox): No
Tuberculosis: No
Any heart complaint/treatment (Especially in the last 3 weeks): No
Any other medical information? If Yes provide details: No
Does your child have any dental anxiety / ADHD— Please provide further information:

Agreed that the above is a true and accurate record of my child’s medical history

PRIVACY STATEMENT

Semper Dental respects your right to privacy and considers all of the information you have provided in this form to be personalinformation for the purposes of the Privacy Act 1988 as amended (“Privacy Act”).

Why Semper Dental collects your personal information?

We collect your personal information primarily to enable us to provide dental care services to you in the most appropriate and efficient way. We may also use this information to promote health and related services to you or for other purposes permitted under the Privacy Act.

How Semper Dental collects your personal information.

1. Where possible we collect your personal information directly from you and where that is not reasonably practicable we may collect your personal information from other sources.

2. By sending these forms to you;

3. In addition, we may collect personal information from Related Persons or health service providers such as health insurers, government agencies, hospitals, doctors and medical specialists.

How does Semper Dental use your personal information?

We use your personal information in accordance with National Privacy Principles.
The personal information is used to:

1. Provide you with health and related services, including appointments and follow up services and

2. Promote the health-related products and services of Semper Dental.

The parent/guardian, confirmed that I have read and accept the privacy statement.

Medicare Charges
88011 - $60.95 Examination
88111 - $62.30 Polish - Removal of plaque
88114 - $103.90 Removal of calculus
88121 - $40.05 Topical application of remineralisation and or Cariostatic agent.
88161 - $53.35 Fissure Sealant

Non eligible families Note below
$115 per a child includes all treatments (excluding fissure sealant)

( We will invoice you for these charges and once paid they may be eligible to be claimed against your private health insurance)

PLEASE ENSURE YOUR MEDICARE DETAILS ARE UP TO DATE WITH MEDICARE.

PLEASE CHECK THAT YOU HAVE COMPLETED ALL SECTIONS OF THIS FORM

Office Use Only

Not Eligible

Paying: No
To Be Treated: No
Treatment Date: N/A

88011
88012
88111
88114
88115
88121
88161
88162
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No