Your kindergarten or childcare

What kindergarden or childcare does your child attend? *

What class or group are they in? *

About your child

Given name *

Family name *

Full name

Preferred name

My child only has one name, a mononymn

Date of birth *

Contact information

If a dental issues is noted, would you like to be contacted for an appointment with IPC afterwards? *

YesNo

Your daytime contact phone number *Mobile phone or best contact option

Address *

Street address *

City *

Postcode *

Ethnicity / Nationality

Is your child: *

Aboriginal Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderNeither

Was the child born overseas? *

YesNo

If yes, Country of Birth

Does your child need an interpreter? *

YesNo

What language or dialect does the child speak? *

Cards and Identification

Do you have a Healthcare or Pension card?

YesNo

What is your card number? *

Expiry Date healthcare/Pension *

About your child's health and wellbeing

These questions are about your child's health and help us provide care that meets their needs.

Has your child had a dental screen /examination before?

Yes No

When was the dental screening *

Is your child taking any medication? *

YesNo

What medication do they take *

Details about your selection *

Do you have any allergies *

YesNo

List your allergies *

Has your child been to hospital? *

YesNo

Reasons for hospital visit *

Does your child have a physical, sensory or intellectual disability? *

YesNo

Details about disability or access needs *

If your child has experienced any problems with dental treatment in the past? What happened?

Do you have any dental worries you would like to discuss?

Consent

I understand that by signing this form I am consenting for my child to have a basic oral health assessment, or dental screen. I understand this screen is only a very basic evaluation and does not take the place of a full comprehensive dental examination. I consent for my child to participate in an oral health screen.

I confirm that above information I have provided is true, complete and accurate.

I understand that IPC Health complies with the Privacy Act (1988) and as part of their privacy policy they are committed to protecting the privacy of individuals and their personal information.

I understand I may withdraw my consent for IPC Health to use and disclose my personal information (except when legal obligations must be met).

I consent to SMS reminders to be sent to me. *

Sign here carefully

Your full name *

Your child's full name *

Relationship to child (Parent/Guardian) *

Take your time and sign as clearly as possible.
We use this signature if you make future requests for your health information.

⚠️ If your signature isn't clear we will ask for a hand drawn version

Signature *

Clear

Date