Child Dental Benefits Schedule Bulk Billing Patient Consent Form

I, the patient / legal guardian, certify that I have been informed:

• of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule;

• of the likely cost of this treatment; and

• that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out of pocket costs for these services, subject to sufficient funds being available under the benefit cap.

Patient’s Medicare number ID
Patient’s full name:
Patient / legal guardian signature:
Full name of person signing (if not the patient):

Date:

This form is valid up to 31 December of the calendar year for which it is signed.