Consent and Enrolment for Oral Health Services

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Oneroa Dental Surgery is pleased to offer free dental treatment again in 2021 to adolescents from School Year 9 until their 18th Birthday.

Treatment will be carried out by Bronwyn Weaver, Dental Therapist under the Combined Dental Agreement contract held by Dr Nick Stretton.

Email *

Treatment that is provided at no charge:

- Annual examination
- Radiographs (x-rays)
- Preventive fluoride application where appropriate
- Fissure sealants
- Scale and polish (cleaning)
- Oral hygiene instruction (teaching brushing techniques)
- Single surface fillings (white, not mercury amalgam)

Treatment that requires Prior Approval from Ministry of Health:

- Extensive fillings
- Splints
- Periodontal disease treatments
- Dentures
- Crowns

Treatment that is NOT provided under the contract, and will therefore charged privately only after you are given a quote and treatment plan:

- Sports mouth guards
- Tooth whitening
- Orthodontic related treatment
- Orthodontic hygiene appointments
- Orthodontic extractions
- Sedation procedures
- ACC treatment

Patient's first name(s): *

Patient's last name(s): *

Date of Birth: *

Sex: *

Male

Female

School attending in 2021: (or note if not attending) *

School Year in 2021: (eg: 9) *

Daytime phone number: *

Mobile phone number: *

Full residential address: *

I wish for the above named patient to be enrolled for oral health services with Oneroa Dental Surgery. Patient and clinical information may be provided on request to the local district health board and the Ministry of Health. If you are under 16 and giving your own consent we suggest you discuss this with your legal guardian.

Required

Full name of legal guardian or patient granting consent *

Any further questions or comments?

A copy of your responses will be emailed to the address you provided.

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