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

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

Enrolment and Consent Form

(e.g. 2B)

Student details

e.g. 21/08/2007

*Invalid date of birth

Parent/Guardian details

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.

Confirm School

Please go back and select the correct school

Student Details (continued)

Enter full number with no spaces
e.g. 04/2025

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.

This includes food, medicines, and/ or products. e.g. latex, band-aids, colophony, rosin, milk protein (casein)
This includes using an asthma inhaler/puffer
e.g. physical disability requiring wheelchair access; sensory or intellectual disability; mental health or psychological condition

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

e.g. asthma, lung disease, TB
e.g. artificial heart valve, pacemaker
e.g. transplant, artificial joint
e.g. stroke, arthritis

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 ...

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

Oral health questionnaire - part 1 (con't)

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

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

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.

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

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:

How much you pay

CDBS bulk-billed fee (we charge Medicare)

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.

How much you pay
CDBS bulk-billed fee (we charge Medicare)
$33.35 per x-ray

How much you pay

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

How much you pay

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

* 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

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.

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.


  • 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:

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.
Draw signature|Type signatureClear

*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.

*Please change to the current date

Submit Form

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