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
Email
This field is for validation purposes and should be left unchanged.