Strong Smiles Assignment of Medicare benefits (bulk-bill) Do you agree to assign the Medicare Benefits as texted or emailed to you?* Yes, I agree to the assignment of Medicare benefits directly to the provider No, I do not agree to the assignment of Medicare benefits directly to the provider Parent / Carer's Name* Parent / Carer's Given Name(s) Parent / Carer's Family Name Child's Name* Child's Given Name Child's Middle Name Child's Family Name Child's Date of Birth* DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged.