Provide Consent – Moviliti Dental Care

1 Patient Details

2 Services

3 Person Providing Consent

Patient Name*
Prefix First Middle Last
Date of Birth*
Facility*
DVA Gold Card Number
Dental Concerns

Comprehensive Dental Examination: $270.00
- Yes
Oral Examination including scale, clean and fluoride. X-rays may be required- which will incur additional fee.
Dental Examination Only: $ 67.00
- Yes
Oral Examination. X-rays may be required which will incur additional fee.
Dental Examination/Denture Hygiene: FULL DENTURES ONLY: $85.00
- Yes
Oral Examination/Denture Review/Denture Clean

Name*
First Last
Address*
Street Address Address Line 2 Suburb State Post Code
Relationship to Patient*
Do you have enduring power of attorney over patient?
- Yes
- No
Phone*
Email*
I hereby consent for Moviliti™ Dental Care to provide a complete Dental Examination. I understand that I am financially responsible for the costs involved. I understand that x-rays may need to be taken at an additional fee.*
- I Do