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Free dental care through the Child and Adolescent Oral Health Service (School Dental Service) is offered to all Queensland students from the age of four to the completion of Grade 10 who are permanent residents of Australia and named on a Medicare card. The dental team consists of a dentist, dental therapists, oral health therapists and dental assistants. You will be advised if your child needs specialist dental treatment.

Students in years 7 to 10 at Harristown Highare now being offered the opportunity to access free dental care through the School Dental Service at the NorthSchool Dental Clinic, Gilbert St, Toowoomba. Children will be offered treatment as family groups. This allows for children in the one family to be treated together, increased parental involvement and a more informed consent.

If wheelchair access or an interpreter service is required parents will need to take their children to the dental clinic at ToowoombaHospital.

If you would like your child/children to participate in the free dental care programme, please complete each section of this registration for oral health services form, sign and return it to the School Office by Friday 12th May 2017.

Please note that by signing this form, you are only advising our service of your wish to participate in the dental care programme and providing personal information to allow us to contact you.

Please remember

  • Appointments are at North School Dental Clinic, Gilbert St, Toowoomba.
  • There are limited appointments available before and after school and most appointments will be during school hours.
  • Oral Health does not accept any responsibility for transport of the children to and from their appointments
  • Parents/Legal Guardian must attend all appointments.
  • Your child must be named on a Medicare Card.

AUTHORITY TO CONTACT - THIS FORM MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN
Important Notice: This authority will remain valid unless revoked in writing
Consent / I give consent to a representative of Queensland Health contacting me regarding oral health services for my child/children via the contact details given below.
Signature / Date____/______/______
NamePlease print / Relationship to child/children

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Home Address
……………………………………………………………………………………………
……………………………………………………………………………………………
Postal Address (if different)
…………………………………………………………...... / Phone (home)
Phone (work)
Phone (mobile)
Fax No.
Email Address
All children registered on this form must attend this school
Child’s Family/Last Name(s) / Date of Birth ___/___/___
Child’s First Name(s) / Male  Female 
Has your child ever been known by another name? No Yes 
If yes, what name were they known as? ______
You must give us your Medicare number to receive an appointment (you must bring your Medicare card to your first appointment)
Medicare Number / Line No: Exp. Date: /
Year Level / Class / Wheelchair Access required / Yes No 
Is your child of Aboriginal or Torres Strait Islander origin? (please tick one box)
No Aboriginal Torres Strait Islander Unknown
In which country was your child born? (please tick one box, and enter name of country if born overseas)
Australia Another country (name of country):......
What language is spoken at home? ………………………………………………………………
Do you need an interpreter? No  Yes If yes, what language? ………………………………
Child No 2
Child’s Family/Last Name(s) / Date of Birth ___/___/___
Child’s First Name(s) / Male  Female 
Has your child ever been known by another name? No Yes 
If yes, what name were they known as? ______
Medicare Number / Line No: Exp. Date: /
Year Level / Class / Wheelchair Access required / Yes No 
Is your child of Aboriginal or Torres Strait Islander origin? (please tick one box)
No Aboriginal Torres Strait Islander Unknown
In which country was your child born? (please tick one box, and enter name of country if born overseas)
Australia Another country (name of country):......
What language is spoken at home? ………………………………………………………………
Do you need an interpreter? No  Yes If yes, what language? ………………………………
Child No 3
Child’s Family/Last Name(s) / Date of Birth ___/___/___
Child’s First Name(s) / Male  Female 
Has your child ever been known by another name? NoYes 
If yes, what name were they known as? ______
Medicare Number / Line No: Exp. Date: /
Year Level / Class / Wheelchair Access required / Yes No 
Is your child of Aboriginal or Torres Strait Islander origin? (please tick one box)
No Aboriginal Torres Strait Islander Unknown
In which country was your child born? (please tick one box, and enter name of country if born overseas)
Australia Another country (name of country):......
What language is spoken at home? ………………………………………………………………
Do you need an interpreter? No  Yes If yes, what language? ………………………………

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