Smile Squad is visiting your school soon.

The Victorian Government's school dental program is FREE to all Victrorian government school students. Sign and submit this consent form to make sure your family does not miss out.

All students can get:

a free dental check-up
preventive services to keep teeth healthy
general treatment (if needed)

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

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

What you need to do:

Read all the information and links in this form
Fill in and sign all forms
- Consent form
- Student details
- Medical history
- Oral health questionnaire
Submit the form as soon as you can
Complete the Child Dental Benefit Schedule bulk billing patient consent (optional) which will be sent in a separate email.

Is there a cost?

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

Privacy

OHV respects your privacy and is committed to protecting your information. Read OHV's full privacy statement

Translations

This Smile Squad consent form uses a machine translator to provide information in different languages. Because the translation is done by a computer, some parts may not be perfect. If something doesn't make sense, please ask a Smile Squad team member for help before you sign.

The consent form is available to read in other languages.

Who can provide consent?

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

Please read carefully

Read the detailed Smile Squad information and services explained sheet on the Smile Squad website.

Feedback

Please tell us what you think (good or bad), at any time. You can email feedback to smilesquad@ohv.org.au

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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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Child Dental Benefits Schedule (CDBS)

Some students may be eligible for the Australian Government's Child Dental Benefits Schedule (CDBS), through Medicare.

The Australian Government allows us to make a claim on your behalf for this dental care if you sign the CDBS consent form.

What is the Child Dental Benefits Schedule (CDBS)?

CDBS is a Medicare program that provides eligible 0-17 year-olds basic dental care over a two-year period.

Smile Squad consent is a two-part consent process. You will receive an email soon with instructions to complete your CDBS consent.

Students can use their CDBS:

for Smile Squad services
at a Victorian public dental clinic
at a private dental clinic

Even if you do not sign the CDBS consent form, every student will still receive free dental care from Smile Squad. There will be no cost to you.

We encourage you to sign the bulk-billing CDBS consent form to allow Smile Squad to claim costs under Medicare. This helps us to provide dental care to more Victorians.

Bulk-billing costs for reference

Medicare requires us to provide you with this information. If you use CDBS these amounts will be taken from your CDBS benefit cap:

Service	CDBS bulk-billed fee	How much you pay
Dental examination (check-up)	$60.95	$0.00
X-rays of teeth (if needed)	$35.30 per x-ray	$0.00
Fissure sealants (if needed)	$53.35 (at most) per tooth	$0.00
Tooth cleaning (if needed)	$103.90 (at most) depending on level of cleaning needed	$0.00
Fluoride varnish application to all teeth (if needed)	$40.05 per application (up to two applications within 12 months)	$0.00

Sign this consent form to take part in Smile Squad

School name *

Grade *

Class *(e.g. 2B)

Student’s first name *

Student's family name *

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

*Invalid date of birth

DOBCalc

I give consent for the student to participate in the Smile Squad school dental program.

I give consent for the student to receive the following services:

Dental examination (check-up) *

YesNo

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

Fissure sealants (if needed) *

YesNo

Fluoride varnish * (if needed) *

YesNo

* May include another fluoride varnish in six months if the student will benefit from it. 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.

Teeth cleaning (if needed) *

YesNo

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

Student details

Gender *

MaleFemaleOther

Please specify *

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

Street address *

Suburb *

State *

Postcode *

Tick if the postal address is different from the student’s address

Postal Address *

Street address *

Suburb *

State *

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.

I confirm I am a mature minor and do not want to nominate a parent guardian. *

First name *

Family name *

Relationship to student *

Mobile number *

Email *

Confirm details

Are these details correct? *

YesNo

First Name:	{{students first name}}
Family Name:	{{students last name}}
Date of Birth:	{{students date of birth}}
School Name:	{{school name}}

Please go back and correct the details

Post Care Report

A Post Care Report with information about the student’s oral health, and any further treatment that may be required, will be provided after each visit.

Do you consent to receive the Post Care Report digitally using the contact details below? *

YesNo

By selecting Yes, you agree to receive the Post Care Report via SMS. If we are unable to reach you by SMS, a copy will be sent to the postal address provided.

A paper report will be provided to the student

SMS:	{{signing parent mobile}}
Postal Address:	{{studentaddress}}

SMS:	{{signing parent mobile}}
Postal Address:	{{postaladdress}}

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 (e.g. asthma)? *

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, attention deficit disorders or autism spectrum disorder)? *

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

Submit form

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.

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:

Dental services

I am aware of 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. All services provided are free.

What if I change my mind?

You can change your mind at anytime. If you no longer consent to be part of Smile Squad, speak to the Smile Squad team at your school or contact your local community dental clinic.

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.

Privacy

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

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 *

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.

EnrolmentConsentDateCalc

Date *

*Please change to the current date

Assigned Agency

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

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