Strong Smiles Registration Form Step 1 of 7 - How it works 14% There are no out-of-pocket costs for this service. If your child is eligible under Medicare’s Child Dental Benefits Schedule, we will bulk bill two item numbers: 88013 ($27.50) for the dental screening 88121 ($34.55) for applying fluoride varnish This form should take around 7-10 minutes to complete per child. To speed up the process, please have your Medicare Card details ready. If you have a Pension or Health Care Card, you’ll need these too. Education Centre detailsSelect your child's childcare/school*Please select your child's education centreGoodstart – Wood St, WarwickGoodstart – Percy St, WarwickHighfields State Secondary College, HighfieldsKingaroy State School, KingaroySt Saviour’s College, Toowoomba We’re sorry, Strong Smiles registrations have closed for Goodstart - Wood St, Warwick For more information about the program, or to contact us, visit: https://www.health.qld.gov.au/darlingdowns/our-services/strong-smiles We’re sorry, Strong Smiles registrations have closed for Goodstart - Percy St, Warwick For more information about the program, or to contact us, visit: https://www.health.qld.gov.au/darlingdowns/our-services/strong-smiles We’re sorry, Strong Smiles registrations have closed for Kingaroy State School For more information about the program, or to contact us, visit: https://www.health.qld.gov.au/darlingdowns/our-services/strong-smiles We’re sorry, Strong Smiles registrations have closed for Highfields State Secondary College For more information about the program, or to contact us, visit: https://www.health.qld.gov.au/darlingdowns/our-services/strong-smiles Your school’s Strong Smiles sessions will be on the 5th, 11th & 12th of October 2021Your school’s Strong Smiles sessions will be on the 1st of November 2021Your school’s Strong Smiles sessions will be on the 11th, 12th, 18th & 19th of October 2021Your childcare centre’s Strong Smiles sessions will be on the 15th & 16th of September 2021Parent/Guardian DetailsName* Parent/Guardian Given Name(s) Parent/Guardian Surname Address* Street Address (i.e. 72 Wendy Street) Suburb Australian Capital TerritoryNorthern TerritoryNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Mobile phone*Do not Include spaces, i.e. 0412345678 Home PhoneInclude: Area Number, i.e. 0746000000 Work PhoneDo not Include spaces, i.e. 0412345678 Email Address* Enter Email Confirm Email Medicare Details Please note: You'll need your Medicare Card details to complete this section. If you have a Pension or Health Care Card, you'll need these details too.Child's Medicare Number:*Do not Include spaces, i.e. 1234567890 Medicare IRN*Select the number that appears next to the child's namePlease select #12345678910111213141516171819202122232425Medicare Card ExpiryMonth*Please select monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Please select year2021202220232024202520262027202820292030 Pension and Health Care Do you have a pension or health care card?* Yes No Type of card Pension Health care card Health care card number Pension card number Pension or health care card expiry MonthPlease select monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYearPlease select year2021202220232024202520262027202820292030 Your Child's DetailsName* Given Name(s) Middle Name Family Name Mobile phoneDo not Include spaces, i.e. 0412345678 Note: We'll use your child's mobile number to remind them about their dental screening appointment.Your relationship to this child* Parent Grandparent Foster Parent Date of Birth* DD slash MM slash YYYY Sex*Please select sexMaleFemaleIndeterminateCountry of BirthPlease select CountryAustraliaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsLanguage spoken at home* English Other Interpreter Required?* Yes - Please include other languages No Include other languages Indigenous status*Please select statusAboriginal but not Torres Strait Islander originTorres Strait Islander but not Aboriginal originBoth Aboriginal and Torres Strait Islander originNeither Aboriginal nor Torres Strait Islander originNot Stated / Unknown Your Child's HealthIs your child allergic to resin (e.g. bandaids) or dairy products?* Yes No Unsure Please select which allergies:* Resin (e.g. bandaids) Dairy products Does your child have any dietary restrictions?* Yes No Unsure Please select your child's dietary restrictions* Dairy Gluten Wheat Other Provide your child's other dietary restrictions Does your child have severe or uncontrolled asthma?* Yes No Does your child have any other significant health issues?* Yes No Please list any other significant health issues Past Dental Visits Has your child visited a Dental Practice (or van) in the last three months?* Yes No Unsure Did your child have a fluoride product applied to his/her teeth during this visit?* Yes No Unsure Treatment options We can offer free treatment for eligible children at our nearest clinic or dental van. However, if you prefer, you can follow up with your own dental practice instead. How would you prefer to receive follow up treatment if it's needed?* Strong Smiles (Queensland Health) Private dental practice Unsure Which private dental practice do you plan to visit for treatment?*To assist in your child's treatment, we will provide the Dental Screen results to your selected private dental practicePlease select private dental practiceChinchilla - Chinchilla Dental PracticeChinchilla - Chinchilla Family DentalCrows Nest - High Country DentalDalby - Dalby Family DentalDalby - Renner DentalDalby - Western Downs Dental & ImplantsGoondiwindi - Dental on BowenGoondiwindi - Goondiwindi Family DentalGoondiwindi - Sparkling White DentalGympie - Channon Lawrence DentalGympie - River DentalHighfields - Gental Dental HighfieldsHighfields - Highfields DentalHighfields - ME Dental Practice HighfieldsInglewood - McIntyre DentalKilcoy - Complete Dentistry KilcoyKingaroy - Dental EssentialsKingaroy - South Burnett Dental GroupKingaroy - VH Complete Dental CareKingsthorpe - Kingsthorpe DentalMurgon - The Country DentistOakey - Kunde DentalOakey - Oakey Family DentalPittsworth - The Avenue DentalStanthorpe - Gentle Family DentistStanthorpe - Granite Belt Dental - StanthorpeToowoomba - 1300SMILESToowoomba - Access DentalToowoomba - Bennett Dental - Anzac AvenueToowoomba - Bennett Dental - Margaret StreetToowoomba - Bickel Dental ServicesToowoomba - Bupa DentalToowoomba - Ewing DentalToowoomba - Garden City Dental PracticeToowoomba - Gentle Dental DraytonToowoomba - Goolburri DentalToowoomba - Heasley DentalToowoomba - Herries Street DentalToowoomba - Jonathan Loughlin DentalToowoomba - Kitchener Street DentalToowoomba - Kunde DentalToowoomba - L & R DentalToowoomba - Maven Dental Tor StreetToowoomba - ME Dental Practice ToowoombaToowoomba - National Dental CareToowoomba - Northpoint Dental CentreToowoomba - Oral Experts Group - Margaret Street DentalToowoomba - Oral Experts Group - Range DentalToowoomba - Oral Experts Group - Southtown DentalToowoomba - Primary DentalToowoomba - Pure Dental ToowoombaToowoomba - Smiles AestheticaToowoomba - Southside Family DentalToowoomba - The Avenue DentalToowoomba - Toowoomba DentalToowoomba - Toowoomba Specialist DentalToowoomba - Westridge DentalToowoomba - Withers DentalWarwick - Country Smiles Dental ServicesWarwick - Granite Belt Dental - WarwickWarwick - Guy Street DentalWarwick - Southern Downs DentalWarwick - Timothy Williams DentalWarwick - Warwick Smiles Dental ClinicWestbrook - Westbrook Family DentalWe will email you with feedback about your child's teeth. Would you also like us to post this feedback to you in the mail?* Yes No Please provide your Postal Address Street Address (i.e. 72 Wendy Street) City Australian Capital TerritoryNorthern TerritoryNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Confirmations & Consent I consent to my child participating in the Strong Smiles program. I agree s/he will have his/her teeth visually inspected and fluoride varnish applied. I have been informed of the treatment that will be provided as part of the Strong Smiles program under the Child Dental Benefits Schedule; of the likely cost of treatment; and that I will not pay out-of-pocket costs for the services. I understand that the cost of these services will reduce the available benefit cap for my child. I understand that Strong Smiles will communicate with me by both SMS and email. If my child is a high school student, Strong Smiles will also send my child SMS messages to remind them about their dental screening. I understand that I may need to bring my child to another appointment if s/he needs further care I consent to information that has been collected by the Department of Health, in the course of my child's oral health care, being used by the Department of Health to check and assess the oral health services my child has received and how such services have been used, provided my child's name is not used in any reports or published statistics I consent for a representative of the Department of Health to contact me via the details I have provided regarding oral health services. This includes texting to the mobile number provided Consent* I confirm that I have read and understand the information above, and agree to my child participating in Darling Downs Health’s Strong Smiles dental screening session for the 2021 school year. NameThis field is for validation purposes and should be left unchanged.