1.

We provide a low cost fee of $50 if your child is not eligible for Medicare.
2.

If they are eligible for Medicare, then we make this claim for you at no cost.
3.

If your child is covered by Private Health Insurance, we can make a no gap claim.

Name of childcare centre

Parent/Guardian

First Name

Last Name

Email

Phone

(###)

###

####

Child's Name

First Name

Last Name

Child’s Date of Birth

MM

DD

YYYY

Medicare Number

Position number of the child on the card

Expiry Date

MM

DD

YYYY

In submitting this form, I consent for my child to have a visit at our childcare centre by Seaford Dental Group.

1.

2.