Smilecare Enrolment & Consent Form
This is the online enrolment and consent form for use by all Smilecare Mobile Services and Smilecare Practices
School Your Child Attends
Botany Downs Secondary
De La Salle College
James Cook High School
Kia Aroha College
Mission Heights Junior
Mt Roskill Grammar
Ormiston Junio College
Ormiston Senior College
Sancta Maria College
Southern Cross Campus
Sir Edemund Hillary Collegiate
Te Kauwhata College
Date of Birth
City or Suburb
Parent or Guardian's Name
Smilecare/MOH Dental Health Package
Your child is entitled to avail of the FREE Dental Health Package from the MOH. Please indicate below if you would like Smilecare to provide your child with this package.
Yes, I give consent for Smilecare to see my child for the Dental Health Package.
No, I do not wan't my child to recieve the Dental Health Package through Smilecare.
If there are any other dental concerns requiring urgent attention I am giving consent for Smilecare to proceed with the treatment provided it is covered by the MOH.
Yes, please proceed with the required treatments
No, please contact me prior to proceeding with the required treatments
If you feel that your child needs orthodontic care then we are more than happy to get in touch with you about our FREE consultation process.
Yes please contact me regarding Orthodontic Care
Any medical conditions we should know about?
Your submission is being processed. Please do not close this browser window until complete.