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Smile in Style Child Dental Benefits

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Name :
*Last Name :
Middle Name : *First Name :

Child Dental Benefits Schedule Bulk Billing Patient Consent Form

I, 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;
- 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.
* 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. I 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.
Patient’s Medicare number:
Patient’s full name:
Patient / legal guardian signature:
Full name of person signing:
form is valid up to 31 December of the calendar year for which it is signed
Your Signature Date