1 Patient Details2 Services3 Person Providing Consent Patient Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Date of Birth* Facility*DVA Gold Card NumberDental 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*SelfMotherFatherSonDaughterBrotherSisterFriendCaregiverOtherDo you have enduring power of attorney over patient?YesNoPhone*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