Dental Planet Enrolment & Consent Form
 
 
Date Today
 
 
 
 
School Your Child Attends*
 
 
Other school (not specified on the list)
 
 
Year Level*
 
 
Child's First Name*
 
 
Child's Last Name*
 
 
Gender*
 
 
 
 
Date of Birth*
 
 
 
 
NHI number
 
 
 
 
Street*
 
 
 
Suburb*
 
 
 
 
City*
 
 
 
 
Postcode
 
 
 
 
Parent/Guardian's Name*
 
 
 
Parent/Guardian's Contact Number*
 
 
 
Parent/Guardian's Email Address*
 
 
 
 
 
 
Dental Health Package
 
 
Your child is entitled to avail the FREE Dental Health Package from the Ministry of Health. Please indicate below if you would like us to provide your child with this package.*
 
Yes - I give consent for my child to receive the Dental Health Package.
No - I do not want my child to receive the Dental Health Package.
 
 
 
 
Other Treatments
 
 
If there are any other dental concerns required, do you give consent for Dental Planet to proceed with the treatment, provided it is covered by the Ministry of Health?*
 
Yes - please proceed with the required treatments.
No - please contact me prior to proceeding with the required treatments.
 
 
 
 
If you feel that your child needs orthodontic care, we are more than happy to get in touch with you about our FREE consultation process. 
Please contact me regarding Orthodontic Care
 
Yes
No
 
 
 
 
Medical history
 
 
Please write any medical condition or allergy that we should know about, and any medication your child is currently taking.