XMM Dental Group Oral Healthcare Adolescent Enrollment and Consent

DATE TODAY

JOIN THE XMM DENTAL GROUP FAMILY

Your child is eligible to recieve FREE general dental care until they turn 18. We would love to be part of your child's journey into adulthood by providing them with quality dental care.

CHILD'S NAME

CHILD'S DATE OF BIRTH

Gender

SCHOOL ATTENDING

CURRENT YEAR LEVEL

WOULD YOU LIKE TO ENROLL YOUR CHILD WITH US

*You will not need to proceed futher if you select NO. Just scroll down and press SUBMIT but please feel free to visit our website should you change your mind in the future. *The awesome clinicians aboard the WAIKIDS or Auckland Regional Dental Service (ARDS) dental bus see your kids only up until their Intermediate years. *If your child is seeing an Orthodontist they may only be looking after the ortho side of things and may not necessarily be able to do the annual check-ups and general treatments.

YES I would like for my child to be enrolled

NO I have another dentist looking after my child

Health Conditions

Does your child have any medical conditions, allergies or is taking any medication we should be aware of?

PARENT OR GUARDIAN'S INFORMATION

NAME OF PARENT OR GUARDIAN FILLING IN THIS FORM

RELATIONSHIP TO THE CHILD

EMAIL ADDRESS

PHONE NUMBER

PREFERRED CONTACT

PHONE

TEXT

ADDRESS

ANNUAL CHECK UP AND TREATMENT CONSENT

Under the Ministry of Health and your local District Health Board's Adolescent Oral Heath Service, your child is eligible to recieve the following basic services: -Annual routine examination to check teeth for decay and look at the gums and mouth for any problems -X-rays used to find tooth decay and other problems that can’t be seen -Fluoride treatment, which helps make the surface of the teeth more resistant to decay -Fissure sealants, which are a thin layer of white filling, painted onto teeth surfaces that are at risk of developing tooth decay -Cleaning away plaque, staining and tartar from teeth -Fillings to restore teeth that have been affected by tooth decay They are also entitled for more complex treatments such as: -Root canal treatment to save teeth that have been severely affected by tooth decay involving the nerve -Extractions to remove teeth that have been badly affected by tooth decay PLEASE READ THROUGH BELOW AND SELECT FROM THE OPTIONS GIVEN.

CONSENT FOR BASIC SERVICES

YES please proceed to provide my child with whatever basic services required.

NO please contact me prior to providing any of the basic services.

CONSENT FOR COMPLEX SERVICES

YES please proceed to provide my child with any of the urgent, complex treatments.

NO please contact me prior to providing any of the urgent, more complex treatments.

LET'S WORK TOGETHER

*We will send through to you the outcomes of your child's initial consultation. *If treatments are required, we would also update you on how these went and if there are any follow-ups or home remedies needed. *In case your child needs to be referred onto a specialist (i.e Orthodontists, Oral Surgeons) we will contact you prior to discuss the situation and make recommendations. *If we see your child at school during school hours, we may need to take them out of class for a short period of time. We coordinate this with the school and make sure they are not disturbed during exams. *If you have other children at the same school whom you'd like for us to see, please click on the ONLINE ENROLLMENT button again though our website and fill in a separate form for them. *Should you have any questions, please feel free to ring us on 0272839257 or 0272705565 email us on mobile@xmm.net.nz

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