Aged Care Dental Consent Form

Before we provide dental care to an aged care resident, we require a completed consent form from a guardian, power of attorney, or responsible person. This form ensures we have the necessary medical, contact, and consent information to deliver safe, respectful care during our visit to the facility.

Aged Care Dental Consent Form

Resident Information

First Name *

Last Name *

Date of birth *

Gender (please tick one) *

Male

Female

Other

Aged Care Facility Name *

Room/Unit Number

Medicare/Private Health Information

Do you have a Medicare Card? *

Yes

No

Medicare Card Number

Medicare Reference Number

Medicare Card Expiry:

Private Health Fund (if any)

Membership Number:

Legal Guardian/Responsible Person

Legal Guardian/Responsible Person Full Name *

Relationship to Resident *

Legal Guardian Phone Number *

Legal Guardian Email Address *

Legal Guardian Postal Address

Medical History

Other (please specify)

Does the resident take any medications? *

Yes

No

List the medications

Allergies (e.g. latex, penicillin)? *

Yes

No

If yes to allergies, please specify

Oral Health & Hygiene

How often are oral hygiene practices performed? *

Daily

Twice Daily

Occasionally

Not regularly

Current oral condition (if known)

Good

Moderate issues

Requires immediate attention

Type of assistance required for dental care *

Independent

Carer-assisted

Fully dependent

Consent for Dental Services

I give permission for the dental team at Tooth Wagon to provide the following services

Consent for Aged Care Dental Services (tick all that apply) *

A comprehensive treatment report will be provided after the visit. For any complex procedures, we will contact the responsible party before proceeding.

Declaration & Consent

By signing this form, I confirm:

I am the legal guardian/power of attorney/responsible person for the resident.
I consent to dental services being provided by the mobile dental team for Tooth Wagon.
I understand services may be bulk billed through Medicare
(if eligible), and any additional costs will be discussed prior.
I acknowledge that this consent remains valid for 12 months unless withdrawn in writing.

Signature

Resident's Name *

Name of person giving consent *

Signature *

Clear

Date of Signing *

What Our Partners Say

⭐⭐⭐⭐⭐

"Tooth Wagon made our annual dental checks so easy. The kids loved the friendly team, and the parents appreciated the convenience.

-Sarah J. (Centre Director)

Bright Futures Daycare

⭐⭐⭐⭐⭐

"The care and respect their team showed our residents was outstanding. It's a vital service that has made a real difference for our community."

-Michael P. (Facility Manager)

Evergreen Aged Care

⭐⭐⭐⭐⭐

"As a parent, knowing my child can get their dental check-up at school is a huge relief. The process was seamless and the report was very clear. Thank you."