Enrolment for Free/funded Dental Care

This Enrolment Form is for Secondary School Aged Teens (up to 17years old).
There are 2 Sections
1. Student/Teen and Parent/Caregiver Information, and
2. Student/Teen Medical Info
NB: An enrolment confirmation and info pack will be emailed to the Primary Contact Parent/caregiver; please contact us if you have any questions - 0800 123 343, thank you.

Students Details

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* 1. Full Name and Date of Birth (DOB)

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* 2. Secondary School Attending (if not attending school please specify e.g. Tertiary course, working...)

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* 4. Gender

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* 5. Ethnicity/s? (e.g. NZ Pakeha/European, NZ Maori, Samoan, Indian) List all that apply.

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* 6. Student Contact Details

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* 7. Parent/Caregiver details (Primary Contact for Student)

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* 8. Other Parent/Caregiver Details

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* 9. When was your/enrolling teens last dental visit?

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* 10. Do you have any concerns about your/enrolling teens Dental Health? e.g. pain, bleeding gums, broken tooth etc

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* 11. Orthodontics: Do you/enrolling teen currently have, or will be getting braces?

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