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. 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, carers 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: www.smilesquad.vic.gov.au

View the DHSV Privacy Statement

Let's start with your mobile number *

Send code

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

Sex *

MaleFemaleOther

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

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

Is an interpreter required? *

YesNo

Preferred language *

Was the student born in Australia? *

YesNo

What country were they born in? *

Medical questionnaire

We ask about these medical conditions as they can impact your child’s dental health or the dental care we provide. We realise that some of these questions are very personal. Please provide information to the best of your knowledge.

I have personal information that I do not wish to write down. I would prefer to speak confidentially with a Smile Squad staff member about this.

Does the student have any allergies? *

YesNo

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

Please provide details *

Has the student been admitted to hospital for severe asthma in the last six months? *

YesNo

Please provide details *

Is the student currently taking any medications? *

YesNo

This includes using an asthma inhaler/puffer

Please provide details *

Does the student have any conditions or disabilities we need to consider when providing their treatment? *

YesNo

e.g. physical disability requiring wheelchair access; sensory or intellectual disability; mental health or psychological condition

Please provide details *

Please tick if the student has ever had any of the following:

Respiratory disease *

YesNo

e.g. asthma, lung disease, TB

Heart condition or heart murmur *

YesNo

Heart surgery *

YesNo

e.g. artificial heart valve, pacemaker

Rheumatic fever *

YesNo

Low or high blood pressure *

YesNo

Treatment for cancer, including chemotherapy or radiation therapy *

YesNo

Excessive bleeding or blood disorder *

YesNo

Other surgery *

YesNo

e.g. transplant, artificial joint

Injury to head, neck or spine *

YesNo

Seizures or epilepsy *

YesNo

Chronic medical condition *

YesNo

e.g. stroke, arthritis

Diabetes *

YesNo

What type? *

Kidney disease *

YesNo

Liver disease *

YesNo

Human papillomavirus (HPV) vaccine (offered to students in year 7 as part of the National Immunisation Program) *

YesNoNot applicable

Is the student or could the student be pregnant? *

YesNoNot applicable

Does the student use tobacco products (smoking)? *

YesNoNot applicable

Does the student use e-cigarettes (vaping)? *

YesNoNot applicable

Does the student drink alcohol? *

YesNoNot applicable

Please give further details *

Any other medical condition *

YesNo

Please provide further details *

Oral health questionnaire - Part 1

Your answers to these questions help Smile Squad understand if there are any aspects of the mouth that concern you. It will help us focus on the things that matter most to you.

Are you concerned that the student ...

Has pain in their mouth? *

YesNo

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

Has trouble eating or drinking because of a problem with their teeth or mouth? *

YesNo

Has trouble speaking clearly because of a problem with their teeth or mouth? *

YesNo

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

YesNo

Doesn’t smile, laugh or show teeth around other students because of a problem with their teeth or mouth? *

YesNo

Has any other problems with their teeth or mouth? *

YesNo

Hidden 1

Please give further details

Oral health questionnaire - part 1 (con't)

Your answers to these questions help us understand each student’s dental experiences.

Has the student had their teeth checked before? *

Yes - private dental clinicYes - public/community dental clinicYes - other/not sureNo

Date of last visit, if known

Is the student currently under the care of a dental specialist? *

YesNo

e.g. orthodontist

Name and address of your dental specialist

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

YesNoI'm not sure

Please give details

Do you have any strategies or supports to help cope better in new situations? *

YesNoI'm not sure

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

Please give details

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

YesNo

Please give details

In the last six months, have any of these stopped the student from getting dental care? *

Distance to nearest dental clinicCostOther reasonNo

Please give details

Oral health questionnaire - Part 2

As well as checking teeth, Smile Squad can work out if a student is likely to get tooth decay in the future. We do this by looking at a student’s current oral health, any previous treatment, and their eating, drinking and brushing habits. Your answers to these questions help us develop the best plan to help keep teeth healthy into the future.

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

YesNoI’m not sure

Please give details

Does the student wear an appliance in their mouth? *

YesNo

e.g. orthodontic plate, retainer, night guard, denture or mouthguard

Please give details

Does the student play sport(s)? *

YesNoI’m not sure

Please give details

How often does the student eat sugary snacks in between meals? *

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

How often does the student drink fruit juice or sugar-sweetened drinks? *

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

What type of water does the student drink at home? *

Tap (unfiltered)Rainwater tank or boreBottledOther (e.g. filtered water)

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

What type of toothpaste does the student use? *

Standard fluoride toothpasteChildren’s fluoride toothpasteNon-fluoride toothpasteDon’t know/not sure

What does the student usually do after tooth brushing? *

Spit out the toothpasteRinse and spitSwallow the toothpasteRinse and swallow

Has the student had fluoride applied to their teeth at a dental clinic in the last six months? *

YesNoI’m not sure

Please give details

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

Does a parent or other adult help the student brush their teeth? *

YesNoNot applicable

What type of help is given? *

Put toothpaste on brush and brush their teethPut toothpaste on brush onlyWatch and give adviceOther

Please provide details *

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. Please use the "Previous" button below to go back.

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.

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Date *

*Please change to the current date

Submit Form

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

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