Oral Health Service Enrolment Form Registration of Child that requires Oral Treatment Child's First Name(s) -Including middle name * Also Known As Child's Surname* Date of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth Gender*MaleFemaleOther Current School Does your child have any medical conditions?*YesNo Please provide a few more details (no more than 20 words)*Additional Children Not Enrolled Names of other children in the family that are ALREADY enrolled. Do you have additional children you would like to enrol?YesNo First Name (Child 2)* Surname (Child 2)* Date of Birth (Child 2)*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth (Child 2) Gender (Child 2)*MaleFemaleOther Current School (Child 2) NHI If Known (Child 2) Do you have additional children you would like to enrol? (3)YesNo First Name (Child 3)* Surname (Child 3)* Date of Birth (Child 3)*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth (Child 3) Gender (Child 3)*MaleFemaleOther Current School (Child 3) NHI If Known (Child 3) Do you have additional children you would like to enrol? (4)YesNo First Name (Child 4)* Surname (Child 4)* Date of Birth (Child 4)*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth (Child 4) Gender (Child 4)*MaleFemaleOther Current School (Child 4) NHI If Known (Child 4) Do you have additional children you would like to enrol? (5)YesNo First Name (Child 5)* Surname (Child 5)* Date of Birth (Child 5)*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth (Child 5) Gender (Child 5)*MaleFemaleOther Current School (Child 5) NHI If Known (Child 5) Do you have additional children you would like to enrol? (6)YesNo First Name (Child 6)* Surname (Child 6)* Date of Birth (Child 6)*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth (Child 6) Gender (Child 6)*MaleFemaleOther Current School (Child 6) NHI If Known (Child 6) Do you have additional children you would like to enrol? (7)YesNo First Name (Child 7)* Surname (Child 7)* Date of Birth (Child 7)*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002year Place of Birth (Child 7) Gender (Child 7)*MaleFemaleOther Current School (Child 7) NHI If Known (Child 7) Please list below known medical conditions for any additional child you have enrolled above:Name of Child:Medical Condition(s):Information about Parent Mother's / Guardian's First Name Mother's Maiden / Guardian's Surname Home Address Address Line 1 Address Line 2 City Postal Code Is your Postal Address different to your Home Address?YesNo Postal Address Street Address Street Address Line 2 City Postal Code Email Mobile Phone Number Home Phone Number Work Phone Number Alternative Contact Name Alternative Contact's Phone NumberEthnicity of Parent Ethnicity*NZ European / PakehaOther EuropeanEuropean [Not Further Defined]NZ MaoriPacific Peoples [Not Further Defined]SamoanCook Island MaoriTonganNiueanTokelauanOther Pacific peoplesAsian [Not Further Defined]Southeast AsianChineseIndianOther AsianMiddle EasternLatin American / HispanicAfrican (or cultural group of African origin)other Iwi/Hapu Please upload or attach the required eligibility documents, such as the child's Birth Certificate or Passport, and if applicable, Parent's Visa.Oral Healthcare ConsentBy giving consent, you or your child are agreeing to receive ongoing oral health care until their 18th birthday.You are consenting to:- a regular dental examination- dental X-rays- preventative care, if required (Fluoride Varnish & Fissure Sealants).These procedures will be explained fully before proceeding at each visit.Click here for further information about dental treatments provided by the Oral Health Service.If your child requires dental treatment additional to examination, dental X-rays and preventative care you will be informed and asked for further consent before treatment begins.If you have any queries about enrollment or wish to attend appointments, please phone 0800 MY TEETH (0800 698 3384). Name of Parent or Guardian giving Consent* I am consenting to the following:*Regular dental examinationsDental X-raysFluoride VarnishFissure Sealants I have the following comments about the procedures and consentSubmitReset