NSW Health Primary School Mobile Dental ProgramInformation and Consent Package for Parents and Guardians

Introduction NSW Health is pleased to offer your child a free school-based dental check-up and preventive care package delivered by NSW Health staff.

The school-based dental service being offered includes the following:

1. An appointment to provide your child with a comprehensive dental check-up and preventive care package

2. A review appointment within 12 months if required

3. Additional treatment at school or in a local dental clinic if your child requires more dental care

All services from NSW Health will be provided at no cost to you.

Other options for dental care for your childIf your child has a regular dental practitioner, you may wish to continue your child’s care with that practitioner1.

Alternatively, you may choose to make an appointment for your child to be seen at a NSW Health public dental clinic. Contact details for NSW Health Public Dental Services are enclosed in this information package. In NSW all primary school children can receive free dental care in public dental clinics.

What is included in this package?This package includes:

1. Information about the services being offered to your child:

- Frequently asked questions

- Privacy statement

- Reference sheet: components of dental care

- Public Dental Service contact details

- Child Dental Benefits Schedule flyer

2. Forms to complete and return to your child's school within two weeks:

Treatment consent form

For your child to receive care, your consent is required. You can withdraw your consent to treatment at any time by contacting your local Public Dental Service. The contact details are enclosed in this information package.

Child Dental Benefits Schedule Bulk Billing Patient Consent form

Public Dental Services in NSW routinely ask parents/guardians to give financial consent for their child’s care to be bulk-billed under the Child Dental Benefits Schedule (CDBS). Regardless of whether your child is CDBS eligible, or whether you choose to give your consent, NSW Health will provide the same level of service to your child at no cost to you. You can withdraw your consent to use the CDBS at any time. More information about the CDBS is enclosed in this information package.

For more information, or if you have any questions, please visit www.health.nsw.gov.au/primaryschooldental or contact your local Public Dental Service using the contact details enclosed in this package.

1. Please note that when visiting a non-NSW Health service, the costs of your child’s care may be covered by private health insurance, the Child Dental Benefits Schedule (if your child is eligible), payments made by you, or a combination of these. Brush your teeth

morning and nightEat more

fruit and vegiesChoose water

as a drinkHave a regular

dental check-up

Frequently asked questions

How will school-based dental care be provided to my child?Dental care will be provided by highly trained NSW Health staff who are experienced in providing dental care to children. This will include a dental practitioner (a dentist or dental therapist/oral health therapist) who will provide the dental check-up and preventive care package for your child. A dental assistant will also be there to help your child feel comfortable and to support the dental practitioner.

The dental team will work either in a designated room in your child’s school using portable dental equipment or in a mobile dental van.

What will happen as part of my child’s care?A dental practitioner will provide a dental check-up and preventive care package for your child. This may include a comprehensive examination (including risk factor assessment, growth assessment and oral health education), dental x-rays, dental clean, fissure sealants and fluoride varnish application. These will be provided if your consent has been given and the dental practitioner determines it is necessary.

A review appointment may be scheduled for your child within 12 months for a brief examination and a second application of fluoride varnish.

If at any stage the dental practitioner considers that your child needs further dental care, you will be contacted to discuss your options in relation to arranging treatment.

Please refer to the 'Reference sheet: components of dental care' for detailed information on the care on offer for your child.

Can I attend my child’s dental appointment?Yes. You are welcome to attend your child’s appointment. Please contact your local Public Dental Service using the contact details enclosed in this information package to find out when your child’s school and/or appointment is scheduled.

How will I know what happened at my child’s dental appointment?A letter outlining what was done at your child’s appointment will be provided. Please keep this letter in a safe place for future reference. A copy of this information will also be kept on your child’s NSW Health oral health record and can be made available at your request.

If your child needs further dental care, you will be contacted to discuss your preferences in relation to arranging treatment.

Can I withdraw consent?Yes. Consent can be withdrawn at any time by contacting your local Public Dental Service. Please see the enclosed Public Dental Service contact details in this package.

What if my child has a dental emergency or a toothache?Signs that your child may need urgent dental care include:

• swelling of the face

• swelling in the mouth

• persistent bleeding in the mouth

• an accident involving damage to the mouth or teeth

• dental pain (e.g. in teeth, mouth, gums or jaw)

After hours you should take your child to your local hospital’s emergency department. During working hours you should call your Local Health District oral health call centre (see enclosed Public Dental Service contact details).

What if my child misses out on receiving a dental check-up at school?If your child misses out on receiving a dental check-up, you can:

• Contact your local Public Dental Service to:

- find out when the next visit to your child’s school is planned or

- make an appointment for your child to be seen at your nearest public dental clinic

• Contact a non-NSW Health dental provider to make an appointment for your child.

What will happen to my child’s information?Please see the Privacy Statement included in this package.

Privacy statement

Our obligations We are committed to treating your and your child’s personal information in accordance with privacy law. This statement explains how and why we collect personal information about you and your child, how you can access your information and how your information may be used within the NSW public health service or disclosed to other parties. Your personal information includes identifying information about you and your child (such as name and address) and personal health information relating to your child’s health and dental care.

CollectionPersonal information is collected so that your child can be provided with the appropriate oral health services. Only information that is relevant and necessary for your child’s oral health and to manage oral health services is collected. Information is collected directly from you and your child, wherever possible. Information may need to be collected from your child’s school and other health practitioners who have treated your child. In an emergency, information may also need to be collected from another family member, friend, carer or other person who can help us to provide your child with the best care.

Security of information collected Personal information may be held in a variety of ways. Most commonly, information may be held as a paper medical record and/or an electronic medical record forming part of a secure computerised database. We follow strict rules and policies regarding the secure storage of personal information in all formats in order to protect your information from loss, unauthorised access and misuse.

Use and disclosure Your personal information or that of your child may be used by the NSW public health service, or disclosed outside the health service, to enable appropriate care and treatment to be provided to your child. For example, personal information may be used or disclosed:

• to your GP, to your child’s GP, to another treating health service or hospital, or to a specialist for a referral

• for purposes relating to the operation of the NSW health service and the treatment of our patients, including funding, planning, safety, and quality improvement activities

• to State and Commonwealth government agencies for statutory reporting purposes, such as to report notifiable diseases and to provide Medicare details

• to contact you regarding client satisfaction surveys

• to researchers for public interest research projects as approved by a Human Research Ethics Committee

• to other agencies where the information relates to the safety, welfare or wellbeing of a child or young person.

Access to your information You are entitled to request access to your personal information and your child’s personal information held by us. Such requests will be treated in accordance with the NSW Health Privacy Manual.

Further Information For further information on how your personal information is managed, please see the NSW Health Privacy Manual for Health Information available at www.health.nsw.gov.au/patients/privacy

If you have questions or a complaint about the privacy of your personal information, please contact your Local Health District or the NSW Ministry of Health using the contact details at www.health.nsw.gov.au/patients/privacy/Pages/privacy-contact.aspx.

Reference sheet: components of dental care

Dental check-up

Component What is it?

Comprehensive examination

A comprehensive examination includes a check of your child’s teeth and gums and a risk factor assessment for dental disease. It is an effective way of detecting dental disease and is necessary to create a plan to promote good oral health for your child.

A dental practitioner will perform a thorough check of your child’s teeth and gums using a small mirror and probe. They will discuss the importance of oral health with your child and how to keep their teeth healthy. This will include advice on foods and drinks for healthy teeth and tips on tooth brushing and oral hygiene.

It is standard practice in NSW Health public dental clinics for all primary school children to have a growth assessment during their dental check-up as a part of good clinical care. This will involve a simple height and weight measurement of your child. It is relevant to assess growth during dental check-ups as some risk factors for oral diseases are shared with being below or above a healthy weight.

Your child’s privacy and wellbeing is extremely important and ensuring your child feels comfortable is a priority for our dental teams.

Dental x-rays Dental x-rays are safe for people of all ages. If you provide consent, the dental practitioner will assess your child’s teeth and decide if dental x-rays are needed. If they are needed, two small x-rays are usually taken. If dental problems are detected, additional x-rays may be required.

Dental x-rays help dental practitioners to check for dental disease. They significantly increase the detection of tooth decay compared with visual examination alone.

Preventive care package

Component What is it? Is it safe? What are the benefits?

Dental clean A dental practitioner may perform a clean of your child’s teeth to remove plaque and calculus - the soft film of bacteria and hard deposits that build up on the teeth over time.

Yes. In some cases a clean may cause temporary irritation, discomfort and/or bleeding of the gums.

The removal of plaque and calculus helps to promote healthy gums and teeth.

Fluoride varnish application

Fluoride varnish is a sticky paste that is applied to the teeth to help prevent tooth decay. It contains high concentration sodium fluoride, a mineral that can strengthen tooth enamel (the outer layer of the tooth).

A dental practitioner will apply a small amount of the varnish to clean, dry teeth using a brush, probe or applicator. Children will be asked to avoid eating for one hour after application.

As part of this program, children can receive two applications of fluoride varnish per year.

Fluoride varnish is safe and is commonly used when treating children and adults.

Adverse effects, including the risk of ingestion and toxicity, are extremely rare. In the event of any adverse effects, the layer of varnish on the teeth may be removed by brushing and rinsing with water.

Fluoride varnish is clinically proven in the prevention of tooth decay.

Fissure sealants A fissure sealant is a resin or glass ionomer based coating which a dental practitioner may apply to the grooves of your child’s permanent back teeth. The fissure sealant forms a long term barrier to food and plaque accumulation, helping to prevent tooth decay.

Fissure sealants may not be needed for children:

-at low risk of tooth decay

- who do not have erupted 6 year old or 12 year old molars.

Fissure sealants are safe and are commonly used in children.

Fissure sealants are clinically proven in the prevention of tooth decay.

Brush your teethmorning and night

Eat morefruit and vegies

Choose wateras a drink

Have a regulardental check-up

Public Dental Service contact details

Enquiries about the NSW Health Primary School Mobile Dental ProgramFor more information about the NSW Health Primary School Mobile Dental Program visit www.health.nsw.gov.au/primaryschooldental or contact your Local Health District public dental service using the contact details below.

Local Health District Phone Email

Western Sydney (02) 8890 7178

South Western Sydney (02) 8738 9082 SWSLHD-ChildDental@health.nsw.gov.au

Nepean Blue Mountains(02) 4734 2387 or 1300 769 221

NBMLHD-OralHealthMDC@health.nsw.gov.au

Central Coast 1300 789 404 CCLHD-MDC@health.nsw.gov.au

Mid North Coast 1300 651 625 MNC-MobileDentalService@health.nsw.gov.au

If you are unsure which Local Health District you live in, please refer to the maps available at www.health.nsw.gov.au/lhd/Pages/lhd-maps.aspx

General enquiries about NSW Health Public Dental ServicesFor more information about NSW Health Public Dental Services visit www.health.nsw.gov.au/oralhealth or contact your Local Health District public dental service. All Local Health Districts have oral health contact centres and their contact details are outlined below.

Local Health District Phone

Sydney South Western Sydney

(02) 9293 3333

South Eastern Sydney 1300 134 226

Illawarra Shoalhaven 1300 369 651

Northern NSW Mid North Coast Hunter New England

1300 651 625

Central Coast 1300 789 404

Northern Sydney 1300 732 503

Murrumbidgee Southern NSW

1800 450 046

Western Sydney (02) 8890 6766

Nepean Blue Mountains (02) 4734 2387 or 1300 769 221

Far West Western NSW

(02) 6809 8621 or 1300 552 626

NSW Health Primary School Mobile Dental ProgramTreatment consent formALL FOUR PAGES OF THIS FORM SHOULD BE COMPLETED TO ENABLE TREATMENT TO PROCEED. Parent/Guardian to complete all fields in CAPITAL letters using a black or blue pen. Please return the completed form to your child's school. If you have any questions about completing this form, please contact your local Public Dental Service using the details on the enclosed information pack.

Student detailsSurname:

Given name/s:

Gender:

Date of birth:

/ /

Country of birth:

Name of School:

School class:

Home address: (eg. 5 Smith Lane)

Suburb:

Postcode:

Medicare Card Number (10 digits):

Child’s number on card:

Medicare expiry date:

Child does not have a Medicare Number:

Requires interpreter:

Yes No

Preferred language (SPECIFY):

Language(s) spoken at home:

English Other (SPECIFY)

Indigenous status:

No

Yes, Aboriginal

Yes, Torres Strait Islander

Yes, both Aboriginal and Torres Strait Islander

Requires Aboriginal health worker:

Yes No

**Please complete and return to your child's school - page 1 of 4**

Your details – Parent or Legal Guardian

Title:

Surname:

Given name/s:

Relationship to the child:

Mobile number:

Alternate contact number:

Email address:

Mailing address (if different to child’s home

address): (eg. 5 Smith Lane)

Suburb:

Postcode:

Medical information Please tick the boxes that apply to your child:

My child has an allergy (e.g. latex, natural resin).

My child has a medical condition.

My child requires regular medication.

My child has a disability.

If you ticked a box above, please describe.

Dental information

Has your child had any dental problems (e.g. tooth decay) in the past?

Yes

No

If you answered yes above, please describe.

When did your child last visit a dental professional?

Less than 12 months ago

More than 12 months ago

Never

Don’t know/unsure

Was your child’s last dental visit made at a:

Private dental practice including health fund dental clinic

Public dental clinic/dental hospital

Any other place

Don't know/unsure

**Please complete and return to your child's school - page 2 of 4**

Please provide the name and contact details of your child's last dental provider

Has your child had a topical fluoride application in the last 6 months?

Yes No Don’t know/unsure

Has your child had dental x-rays in the last 6 months?

Yes No Don’t know/unsure

Risk factor informationTo help us assess your child’s teeth, please tick the most appropriate box and specify the quantities where required:

1. How often does your child usually drink sugar sweetened drinks such as soft drinks, cordials, sports drinks, energy drinks or iced teas? (1 cup=250ml. 1 can of soft drink = 1.5 cups. 1 500ml bottle of sports drink = 2 cups)

Every day

Approximate number of cups per day:

A few times a week

Approximate number of cups in a week:

Rarely or never

Don't know/unsure

2. How often does your child usually drink water? (1 cup = 250ml or a household tea cup. 1 600ml bottle of water = 2.4 cups)

Every day

Approximate number of cups per day:

A few times a week

Approximate number of cups in a week:

Rarely or never

Don't know/unsure

3. How often does your child usually eat sweet biscuits, cakes, pastries, or snack bars? (Snack bars include muesli bars, breakfast bars and protein/energy bars and balls)

Every day

Approximate number per day:

A few times a week

Approximate number in a week:

Rarely or never

Don’t know/unsure

4. How often does your child brush his/her teeth with toothpaste?

Rarely or never

Less than once/day

Once a day

Twice a day

More than twice a day

Don’t know/unsure

5. What type of toothpaste does your child use?

Standard fluoride toothpaste

Children’s fluoride toothpaste

Non-fluoride toothpaste

Don’t know/unsure

6. How do you rate your child’s teeth and mouth?

Poor

Fair

Good

Very good

Excellent

**Please complete and return to your child's school - page 3 of 4**

Treatment consent• I have read and understood the information provided about the school-based dental service including the

safety and benefits of the dental check-up and preventive care package outlined in the Reference sheet: components of dental care.

• I understand that I can withdraw consent at any time.

• I have had an opportunity to ask questions and seek clarification on the information I have been provided by calling the Public Dental Service contact numbers enclosed in the information package.

• I understand that a Local Health District representative may contact me to clarify any of the information provided in this form and/or to discuss my child’s oral health.

• I have been provided with a copy of the Privacy Statement and I understand that my and/or my child’s personal information (including health information) may be disclosed in certain circumstances as set out in that Statement.

• I declare to the best of my knowledge that I have provided accurate information about my child including any medical conditions which may affect dental treatment.

Please sign next to EACH treatment you wish your child to receive. If you wish your child to receive the complete dental check-up and preventive care package, you should sign in each of the five boxes below.

I (full name)

on (today’s date), / / sign below to provide consent for my

child (full name)

(date of birth), / / to receive the following, as clinically needed:

Treatment Description Parent/Guardian signature

Dental check-up Comprehensive examination including risk factor assessment, growth assessment, and oral health education

Dental x-rays On average, two small dental x-rays

Dental clean A clean of the teeth to remove plaque and/or calculus

Fissure sealants Sealing the grooves of up to 8 permanent molar teeth

Fluoride varnish application

Application of a sticky fluoride paste to the teeth to reduce the risk of tooth decay

• This signed consent will be valid for 12 months and a new consent form will be sent out annually.

• If, at any time, you wish to withdraw consent to your child’s participation please follow the instructions in the Information and Consent Package for Parents and Guardians.

Do you wish to attend your child's appointment? Yes No

Only complete this section if you DO NOT CONSENT for your child to participate in the NSW Health Primary School Mobile Dental Program (optional)

2 0

**Please complete and return to your child's school - page 4 of 4**

I do not consent for my child to receive treatment under the NSW Health Primary School Mobile Dental

Program for the following reasons:

My child has a regular dentist Other Please describe

NSW Health Primary School Mobile Dental Program Child Dental Benefits Schedule information sheet

Dental care for children in NSW• All children (under 18 years old) can access

free public dental services in NSW • Some children may also be eligible for the

Commonwealth’s Child Dental Benefits Schedule (CDBS)

• Regardless of whether your child is eligible for the CDBS, they will receive the same high standard of care that all NSW public dental patients receive at no cost to you

What is the Child Dental Benefits Schedule?The CDBS gives eligible children access to up to $1,000 in benefits for dental services over two calendar years.

Children are eligible for the CDBS if they are:

• Aged 2 to 17 years for any one day of the calendar year and

• Eligible for Medicare and

• Part of a family that receives Family Tax Benefit Part A or the child receives an Australian Government payment from the list available through the Department of Human Services.

You don’t need to register your child for the CDBS. Families will be advised by the Department of Human Services if their child is eligible.

What services are covered by the CDBS?A range of services can be provided under the CDBS including:

• Examinations

• X-rays

• Cleaning

• Fluoride varnish

• Fissure sealants

• Fillings

• Extractions

CDBS benefits are not available for orthodontic or cosmetic dental work or any services provided during a stay in hospital (including day surgery).

How can my child access the CDBS?Your child can access dental care under the CDBS through the NSW Public Dental Service, including the NSW Health school-based dental service, or through a private dental practitioner.

When your child attends a public dental service, you will be asked to sign a form (enclosed in this consent package) giving us permission to bulk-bill for services under the CDBS.

Even if the $1,000 benefit cap is reached, or your child needs treatment not covered by the CDBS, NSW Public Dental Services will not charge for these services.

To find out more information:Visit www.health.nsw.gov.au/cdbs or visit the Australian Government’s Department of Human Services website at www.humanservices.gov.au/individuals/services/medicare/child-dental-benefits-schedule.

You can check your child’s eligibility and CDBS balance through your Medicare online account at my.gov.au or by calling 132 011.

Brush your teethmorning and night

Eat morefruit and vegies

Choose wateras a drink

Have a regulardental check-up

NSW Health Primary School Mobile Dental Program

Guide to financial consent form to bulk-bill under the Commonwealth Child Dental Benefits Schedule The Child Dental Benefits Schedule Bulk Billing Patient Consent Form allows the Public Dental Service to bulk-bill for dental care provided to your child under the Child Dental Benefits Schedule (CDBS). There will be no out-of-pocket costs, regardless of whether you sign the form to provide financial consent for the CDBS to be used. You can withdraw your consent to use the CDBS at any time.

CDBS value of treatment providedIf you give financial consent, the following amounts may be claimed from your child’s CDBS benefits. You do not need to pay these amounts.

First appointmentThe expected maximum value of treatment that may be claimed under the CDBS for your child’s first appointment is outlined in the table below.

Treatment description Treatment item code CDBS Value

Dental check-up 88011 $52.65

Two small dental x-rays 88022 x 2 $30.45 x 2

A clean of the teeth to remove plaque 88111 * $53.80

A clean of the teeth to remove calculus 88114 * $89.70

Application of fluoride varnish 88121 $34.55

Fissure sealing the grooves of up to 8 permanent molar teeth

88161 x 4 $46.05 x 4

88162 x 4 $23.05 x 4

Total cost $514.20

*Please note that only one of these two items may be claimed in an appointment.

Review appointment (if required)

The expected maximum value of treatment that may be claimed under the CDBS for your child’s review appointment is outlined in the table below.

Treatment description Treatment item code CDBS Value

Dental check-up/review 88013 $27.50

Application of fluoride varnish 88121 $34.55

Total cost $62.05

For more information about the CDBS, please see the reverse of this Child Dental Benefits Schedule Flyer.

Brush your teethmorning and night

Eat morefruit and vegies

Choose wateras a drink

Have a regulardental check-up

CHILD DENTAL BENEFITS SCHEDULE

BULK BILLING PATIENT CONSENT FORM

I, the patient / legal guardian, certify that I have been informed:

of the treatment that has been or will be provided from this date under the Child Dental

Benefits Schedule;

of the likely cost of this treatment; and

that I will be bulk billed for services under the Child Dental Benefits Schedule and I will

not pay out-of-pocket costs for these services, subject to sufficient funds being available

under the benefit cap.

I understand that I / the patient will only have access to dental benefits of up to the benefit

cap.

I understand that benefits for some services may have restrictions and that Child Dental

Benefits Schedule covers a limited range of services. I understand I will need to personally

meet the costs of any services not covered by the Child Dental Benefits Schedule.

I understand that the cost of services will reduce the available benefit cap and that I will

need to personally meet the costs of any additional services once benefits are exhausted.

___________________________ ___________________________

Patient’s Medicare number Patient / legal guardian signature

___________________________ ___________________________

Patient’s full name Full name of person signing

(if not the patient)

___________________________

Date

This form is valid up to 31 December of the calendar year for which it is signed.