What is Smile Squad?

Smile Squad is the Victorian Government free school dental program. Smile Squad provides free dental services to students at school during school hours and at local community dental clinics. This includes any general treatment that is needed.

Do I need to pay anything?

No. This is a free service for all students, provided by the Victorian Government.

Who can provide consent?

Parents, legal guardians or mature minors may complete this form and provide consent for examination.

For more detail

Read the detailed information sheet on the Smile Squad website.

Need assistance?

For more information, or if you need help filling in the form:

Email: smilesquad@dhsv.org.au
Phone: 1300 503 977
Visit: https://www.health.vic.gov.au/smile-squad

View the DHSV Privacy Statement

Let's start with your mobile number *

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This should be the mobile number of the person completing this form

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Enrolment and consent form

School name *

Grade *

Class *(e.g. 2B)

Assigned Agency

Student details

Student’s first name *

Student's family name *

Student’s date of birth *e.g. 21/08/2007

*Invalid date of birth

DOBCalc

Gender *

MaleFemaleOther

Please specify *

What are the student's preferred personal pronouns? (Optional)

Address *

Suburb *

Postcode *

Parent/guardian details

I am a mature minor student and do not wish to nominate a parent/guardian

(Secondary school students only)

In Victoria, the law recognises that as children become older and more mature, they are more capable of making their own decisions, including seeking and obtaining their own health care. To be considered a mature minor, the Smile Squad clinician must be satisfied that the student has sufficient understanding of the risks, benefits, and possible complications of their condition and proposed treatment to give informed consent.

First name *

Family name *

Relationship to student *

Mobile number *

Email *

Confirm school

Is this school correct? *

YesNo

Please go back and select the correct school

Student Details (continued)

Is the student Aboriginal or Torres Strait Islander? *

Is the student an asylum seeker or refugee? *

No, neither asylum seeker nor refugeeAsylum seekerRefugeePrefer not to say

Is an interpreter required? *

YesNo

Preferred language *

Was the student born in Australia? *

YesNo

What country were they born in? *

Do you have a Medicare Card? *

YesNo

Medicare card number *Enter full number with no spaces

Individual reference number *

Expiry date *e.g. 04/2025

Medical history

Does the student have any known allergies? *

YesNo

This includes food, medicines, and/ or products. e.g. latex, band-aids, colophony, rosin, milk protein (casein)

Is the student currently taking any medications? *

YesNo

This includes using an asthma inhaler/puffer

Please list medication name, dose and frequency *

Does the student have any lung conditions? *

YesNo

AsthmaLung diseaseTuberculosisOther

If hospitalised, list month and year

Does the student have a heart (cardiovascular) condition? *

YesNo

Does the student have any sensory, cognitive conditions or additional needs (disability)? *

YesNo

Does the student have any other health or medical condition? *

YesNo

Could the student be pregnant? *

YesNoNot applicable

Does the student use tobacco products (smoking) or e-cigarettes (vaping)? *

YesNoNot applicable

SmokingVapingOther

Does the student drink alcohol? *

YesNoNot applicable

Hidden - Other

If you answered other to any of the above, please describe *

Oral health questionnaire

We ask the following questions to help us understand more about the student and develop the best plan for them.

Does the student have pain in their mouth? *

YesNo

e.g. trouble sleeping because of a problem with teeth

Does the student have trouble eating or drinking because of a problem with their teeth or mouth? *

YesNo

Does the student have trouble speaking clearly because of a problem with their teeth or mouth? *

YesNo

Has the student missed school or other activities because of a problem with their teeth or mouth? *

YesNo

Does the student not smile, laugh or show teeth around other students because of a problem with their teeth or mouth? *

YesNo

Has the student had their teeth checked before? *

YesNo

Date if known

Has the student had any teeth filled or taken out due to tooth decay in the past three years? *

YesNoI’m not sure

How often does the student have sugar sweetened drinks like fruit juice, soft drink or cordial? *

Three or more times a dayOnce or twice a dayA few times a weekAlmost never

How often does the student brush their teeth with toothpaste? *

Does the student have any fears or sensitivities, or negative experiences during or after previous dental visits we should know about? *

YesNo

Does the student use any strategies or supports to help cope better? *

YesNo

e.g. favourite toy, iPhone app, book.

Provide details below and please bring along to next visit

Does any family member or person living in the same house as the student have significant problems with their teeth and/ or gums? *

YesNoI’m not sure

Is there anything else you would like us to know before we check the student’s teeth and mouth? *

YesNo

Please provide detail below

Bulk-billing patient consent

Medicare requires we provide the below information to you. If you use Child Dental Benefits Schedule (CDBS) these amounts get taken from your CDBS benefit cap:

The student can receive the following services:

Dental examination (check-up) *

YesNo

How much you pay
$0

CDBS bulk-billed fee (we charge Medicare)
$57.65

Are you sure you want to select NO? This means you do not provide permission for your child to be seen by Smile Squad.

If this a mistake, please go back and select YES.

X-rays of teeth (if needed) *

YesNo

How much you pay
$0

CDBS bulk-billed fee (we charge Medicare)
$33.35 per x-ray

Fissure sealants (if needed) *

YesNo

How much you pay
$0

CDBS bulk-billed fee (we charge Medicare)
$50.45 (at most) per tooth

Teeth cleaning (if needed) *

YesNo

How much you pay
$0

CDBS bulk-billed fee (we charge Medicare)
$98.20 (at most) depending on level of cleaning needed

Fluoride varnish * (if needed) *

YesNo

* Varnish products may not be suitable if your child has an allergy to band-aids, colophony, rosin, milk protein (casein), or has severe asthma. Please let us know in the allergies section of the Medical questionnaire.

How much you pay
$0

CDBS bulk-billed fee (we charge Medicare)
$37.85 per application
(up to two applications within 12 months)

We are training the next generation of oral health professionals. The student might be seen by a dental/oral health student working under supervision of a qualified Smile Squad clinician.

Do you consent for the student to be seen by a dental/oral health student? *

YesNo

Consent to take part in Smile Squad

Dental services

I understand the types of dental services offered by Smile Squad, including the benefits and risks involved, where the services will take place, and who will be providing them.

Care after dental services

I understand that a Smile Squad clinician or school staff may contact a parent, legal guardian, or carer if a student becomes unwell at school after receiving dental services, or if they require additional care that cannot be managed at school.

Bulk-billing patient consent

I understand that I will not pay any out-of-pocket costs for services provided by Smile Squad.

Privacy

I have read and understood the privacy information and acknowledge how the program will manage student healthcare information.

In giving consent, I agree that I have read this consent form and the Smile Squad information sheet. I have enough information to understand the following:

I give consent for the (named) student to participate in the Smile Squad school dental program. *

I agree that I have, to the best of my knowledge, provided Smile Squad with all the relevant health and personal information that is required to provide appropriate care. *

Parent/guardian/student* full name *

Signing parent/guardian/student* email *

Send code

Once you submit this form, we will email you the Medicare consent form to this email address. It is important that you complete the Medicare consent form as soon as you can.

Parent/guardian/student* signature *

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*Students aged 18 years and over, and those who are considered a mature minor for the purpose of accessing dental services can consent for themselves. This consent is valid for 12 months from the date it is signed.

EnrolmentConsentDateCalc

Date *

*Please change to the current date

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Click 'Submit' to complete the form or go back to change your responses.

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