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The Whole Bite Club
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One cover sheet, then 1 consent form, one per child. Print single-sided on A4.

Kept for four years from the date of service, as the CDBS Guide requires.

The Whole Bite Club

Your child’s Whole Bite Club visit

School or centre
To be written in
Class or room
To be written in
Visit date
To be confirmed

The Whole Bite Club is coming to your school. Your child will play games, learn about teeth, and see an oral health therapist.

The check is quick and gentle. We look at your child’s teeth and count them. We tell you what we saw.

What happens on the day

On the day your child gets a risk assessment, a clean and a check-up. If a tooth needs it, the team may paint on a protective coating: a remineralising varnish, or, on a spot that already has decay, a silver treatment that stops it and can leave that spot dark. The clinical names are fluoride varnish and silver diamine fluoride. To opt out of either, or to supply your own toothpaste, email admin@oralhealthhome.com.

What the check-up costs you

If your family gets Family Tax Benefit Part A, the check-up is free. Some other Centrelink payments count too. Your child needs a Medicare card. Not covered? Your child is still seen on the day, at no cost to you.

What to send back

Please sign both forms in this pack. Send them back to school as soon as you can.

Your free pack

Every child we check gets a free toothbrush + toothpaste pack to take home.

If the form does not come back

No form, no check. Your child can still join the lesson and the games.

Do you have a question? Ask the school office. Or email us.

Oral Health Home · admin@oralhealthhome.com · www.oralhealthhome.com

Prototype pack. Not for use with families.

A blank form for each child

Print one for each child.

Child Dental Benefits Schedule

Bulk Billing Patient Consent Form

About this Program

The Child Dental Benefits Schedule (CDBS) is an Australian Government program that provides access to basic dental services, within a benefit cap, over a relevant two calendar year period. Services that receive a benefit under the CDBS include examinations, cleaning, x-rays, fissure sealing, fillings, root canals, extractions and partial dentures. The full list of services is available in the Dental Benefits Schedule. The Schedule includes an item number, description, benefit amount and applicable restrictions for each service. Services can be provided in a public or private setting. However, benefits are not available for orthodontics, cosmetic dental or any services provided in a hospital.

A child is eligible for the CDBS if they are:

  • 0-17 years old for at least one day that calendar year;
  • Eligible for Medicare; and
  • Receive a payment from Services Australia at least once a year, or have a parent, carer or guardian who receives a payment from Services Australia at least once a year.

Privacy and Consent information

Your personal information is protected by law, including the Privacy Act 1988 and the Australian Privacy Principles (APPs), and is being collected by your Dental Provider on behalf of the Department of Health, Disability and Ageing (the department). for the primary purpose of facilitating basic dental services under the Child Dental Benefits Schedule.

If you do not provide this information services will not be able to be provided to you under the CDBS.

By providing your personal information to your Dental Provider you consent to the department collecting this personal information about you from your Dental Provider.

You can access the department's APP privacy policy at https://www.health.gov.au/resources/publications/privacy-policy

The department can be contacted by telephone on (02) 6289 1555 or via email at privacy@health.gov.au

The department will not disclose your personal information to any overseas recipients.

Patient's details

Medicare card number

Ref

MrMrsMissMsOther

Given Name

 

Family Name

 

Date of Birth

 

I, the patient/parent/carer/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 and the likely cost of this treatment.
  • That I will be bulk billed for services under the Child Dental Benefits Schedule.
  • There will be no out-of-pocket costs for dental services provided within a public clinic.
  • That benefits for some services may have restrictions, and that the Child Dental Benefits Schedule covers a limited range of dental services.

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

PLEASE FILE THIS FORM WITH THE PATIENT'S RECORDS.

Signature

Full name (print in BLOCK LETTERS)

 

Signature

 

Date

 

PatientParentCarer / Guardian

(tick one only)

Version date: June 2026