Mobile Adolescent Dental Enrolment Form
We provide FREE yearly treatment for adolescents up until their 18th birthday. We service the following colleges: Tauranga Boys, Tauranga Girls, Otumoetai, Papamoa and Te Puke. 

Our Mobile Dental Unit will be onsite at Papamoa College part time during terms three and four treating students who are enrolled with us. 

PLEASE NOTE: Students can only be enrolled with ONE Dental Provider.

If you would like your child to be seen by our Community Dental Service at School, then please complete this consent form.
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Email *
First Name *
Middle Name
Family Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Required
NHI (if known)
Ethnicity ( select from the following) *
Required
If selected 'Other' to above, please specify
Has your adolescent attended a dentist in 12 months *
Dentist Name
Next section  - Address details
Enter street name and number *
Enter City/Town *
Enter postal code *
Enter home phone
Enter mobile number *
Enter email address *
Next section -  Emergency contact / Next of Kin details
Enter Name *
Enter Relationship *
Enter home phone
Enter mobile number *
Next section -- Medical History
Have you experienced any of the following conditions? *
Required
Enter name of current GP *
Enter GP contact number *
Have you experienced any allergic reactions? *
If selected 'Yes' to the above questions, please specify
Any allergic reactions to Penicillin, Anesthesia Alert, Latex allergy, Anaphylaxis *
If selected 'Yes / Maybe' above, please specify
Medication Management
To ensure safe management of your oral health needs, please list any medications that you are currently on,  and  state why on next section
Are you on any medications currently? *
List the medications and state the reason
Are you pregnant? *
Required
Are you taking any Birth Control pills? *
Consent for Enrolment
If you DO NOT want your child to be seen and/or they are currently enrolled with a private Dental provider, please select NO and sign below
Are you consenting to free Annual examination / cleaning & scaling  and Fluoride treatment if required *
I am authorized to sign this form because I am *
Print Name *
A copy of your responses will be emailed to the address you provided.
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