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About Us
Our Services
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Consent Form
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Child's Information

Full Name:*

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Medicare Card Number:*

Reference Number:*

Expiry Date:*

Day

Month

Year

Parent/Guardian Name(s):*

Contact number:

Address:*

Past/Current medical conditions

Are you receiving any medical treatment at present?*

Yes

No

Have you had any serious or long standing illness?*

Yes

No

Have you ever been hospitalized?*

Yes

No

Any heart complaint/treatment*

Yes

No

Rheumatic fever or heart values surgery*

Yes

No

High or Low blood pressure*

Yes

No

Blood disorder/bleeding disorders*

Yes

No

Epilepsy*

Yes

No

Diabetes*

Yes

No

Familial disease*

Yes

No

Infectious disease (measles/ chicken pox) especially in the last three weeks*

Yes

No

Tuberculosis*

Yes

No

Any nervous system disorder*

Yes

No

Thyroid disease*

Yes

No

Treatment for any form of cancer*

Yes

No

Does your child experience any of the following?*

Kidney condition

Asthma

Bronchitis

Lung conditions

Radiation Therapy or Chemotherapy

Hepatitis, Jaundice or Liver Disease

Transplanted Organ or Bone Marrow

Other

None

Details if YES to any of the above:

Is your child up to date with immunizations?*

Yes

No

Any Allergies (eg. latex, penicillin, etc):

Current Medications:

Parental Consent & Signature*

I confirm that the above information is accurate to the best of my knowledge. I give consent for my child to receive dental care and treatment as needed.

Parent/Guardian Signature: *

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NATION SMILE MOBILE DENTAL CLINICS

07-3012-6391

info@nationsmile.com.au

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