Dental Planet Enrolment
& Consent Form
School
*
ACG Parnell College
Auckland Grammar School
Baradene College of the Sacred Heart
Bay of Islands College
Botany Downs Secondary College
Cambridge High School
Dargaville High School
Edgewater College
Elim Christian College
Forest View High School
Glendowie College
Howick College
James Cook High School
Kristin School
Mahurangi College
Mangakahia Area School
Mangere College
Mt Roskill Grammar School
Northland College
Not attending any school
Okaihau College
One Tree Hill College
OneSchool Global
Orewa College
Other (please specify below)
Otorohanga College
Papakura High School
Rangitoto College
Ruawai College
Sacred Heart College
Selwyn College
Taipa Area School
Taumarunui High School
Te Kuiti High School
Te Kura Kaupapa Maori o Puau Te Moananui-a-Kiwa
Te Kura Kaupapa Maori o Taumarunui
Te Kura Maori O Nga Tapuwae
Te Kura o Ngapuke
Te Kuru Kaupapa Maori O Hoani Waititi
Te Wharekura O Manurewa
Thames High School
Waiheke High School
Whangarei Boys' High School
Whangarei Girls' High School
Whangaroa College
Other school (not specified on the list)
Year Level (We can only see students from school Year 9 to 13. If your child will be in Year 9 next year, please choose "Incoming Year 9")
*
9
10
11
12
13
Not At School
Incoming Year 9
Child's First Name
*
Child's Last Name
*
Date of birth
*
Gender
*
Male
Female
Other
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.
You will not need to proceed further if you select NO. Just scroll down and press SUBMIT but please feel free to visit our website should you change your mind in the future.
If your child is seeing an Orthodontist they may only be looking after the ortho side of things and may not necessarily be able to do the annual check-ups and general treatments.
Name Of Parent or Guardian Filling In This Form
Relationship to the Child
Email Address
Home Address
Phone number
Preferred Contact
EMAIL
PHONE
TEXT
ADDRESS
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.
I would like to be kept informed.Send me email updates,special offers,and other promotional materials from Dental Planet.I'm aware that I can opt out any time.
Yes
No