Domiciliary Dentistry Program Dental Health Services Victoria Level 4, 720 Swanston Street, Carlton Vic 3053 Tel:

(03) 9341 1000 Fax: (03) 9341 1214

Domiciliary Dentistry Program Application Form

Thank you for your enquiry about our Domiciliary Dentistry (DOM) program. Please find enclosed an application form that we will require you to complete before we can arrange for a dental examination and/or dental treatment. Completing the Application Form To assist us in processing your application as soon as possible, please note the following: Please ensure the consent section on the application form is completed by the patient and/or appropriate guardian/person responsible for the patient. For a definition of person responsible please see over the page. In the absence of a person responsible, please advise the Domiciliary Admissions Officer. Please include any recent dental radiographs that you may have with the application.

Once you have completed the Application Form, please ensure the patients medical practitioner completes the Medical Questionnaire. If your Medical Practitioner can print out a medical summary sheet, please include this with the application. Having completed both parts of the application form please return it to: Admissions Officer Domiciliary Dental Program Royal Dental Hospital of Melbourne GPO Box 1273L Melbourne Vic 3001

or

Fax to: (03) 9341 1214

Please be assured that all information you provide remains confidential. It is stored, maintained and used by Dental Health Services Victoria dental staff according to the Information Privacy Act 2000 (Vic) and the Health Records Act 2001 (Vic) (both as amended or replaced from time to time), that safeguards your Privacy and Confidentiality. More information about protecting your privacy can be obtained from the Domiciliary Dental program on telephone: (03) 9341 1000. Emergency Treatment If required, the Domiciliary Dentistry Application Form may be faxed to the Admissions Officer on (03) 9341 1214, marked URGENT, or call the Triage Officer on 9341 1000 located on the 1st Floor of The Royal Dental Hospital of Melbourne, 720 Swanston Street, Carlton. Charges apply. Treatment cannot be provided without a valid consent.

Thank you for your assistance with the completion of the Application Form.

Page 1

Domiciliary Dentistry Program Dental Health Services Victoria Level 4, 720 Swanston Street, Carlton Vic 3053 Tel: (03) 9341 1000 Fax: (03) 9341 1214

Person Responsible Definition The person responsible is the first person, in descending order, on the following list who is reasonably available, and is willing and able to make a medical or dental treatment decision on behalf of the patient: o A person who is the patients medical enduring power of attorney appointed (before the patient became incapable of giving consent) under the Medical Treatment Act 1988; A person appointed by the Victorian Civil and Administrative Tribunal (VCAT) to make decisions about the proposed treatment; A person appointed by VCAT to act as a guardian who has the power to make decisions about the proposed treatment A person appointed by the patient (before the patient became incapable of giving consent) as an enduring guardian with the power to make decisions about the proposed treatment; A person appointed in writing by the patient to make decisions about medical or dental treatment which includes the proposed treatment; The patients spouse or domestic partner; The patients primary carer, including carers in receipt of a Centrelink Carers Payment but excluding paid carers or service providers; The patients nearest relative over the age of 18, which means (in order of preference): Son or daughter Father or mother Brother or sister (including adopted persons and step relationships Grandfather or grandmother Grandson or granddaughter Uncle or aunt Nephew or niece.

o o o

o o o o

If you are unsure of who can sign the consent section please contact the Domiciliary Dental Program on telephone 9341 1034 for assistance and/or a copy of the fact sheet from the Office of the Public Advocate. The OPA Fact sheet is also online at http://www.publicadvocate.vic.gov.au/medical-consent/176/ Special Needs Dentistry Application Form Checklist
Please ensure the following are complete before returning the application form:
Section A Patient details Section B Eligibility details Section C Patient Consent / Person Responsible details Section D Consent - including (1) patients name and (2) consenting name and signature Section E Current dental needs Section F Dental history Section G Medical Questionnaire (completed by your medical practitioner). Any recent Dental Radiographs are attached

Page 2

Domiciliary Dentistry Program Dental Health Services Victoria Level 4, 720 Swanston Street, Carlton Vic 3053 Tel: (03) 9341 1000 Fax: (03) 9341 1214

Domiciliary Dentistry Program

Application form for dental examination
A. Patient Details: Surname: .. Given Name(s): ........... Title: Mr / Mrs / Ms / Miss / Master Type of residence: Own SRS SSA Date of Birth: ______/_______/__________ Residential Aged Care Level of care: Low High

Name of Residential Facility (if applicable).... Address: ..........................................................................Postcode: ..... Telephone number(s): ...............(Patient//Room) .(RAC Unit/Switch) Country of birth: .. Language(s) Spoken: ..... Are you of Aboriginal origin? Yes / No Are you of Torres Strait Islander origin? Yes / No Name of Carer or Alternative Contact Person: ......Phone: ........ B. Eligibility Details: Card type (please tick) Medicare Card number: .. Expiry Date: . Pensioner Concession Card Health Care Card Other card (please specify): Department of Veterans Affairs Gold Card Department of Veterans Affairs White Card I do not hold a Government Concession card

Card number: Expiry Date: ........ C. Patient Consent / Person Responsible Details: Can the patient provide self consent? Yes / No

If no: The Person Responsible for the patients medical and dental care must complete consent. Person Responsible Details: Surname: .. Given Name(s): ....... Address: ..Phone: ..... Person Responsible / Relationship to patient: .. Please tick if there is no Person Responsible to give consent for the patients medical and dental care: D. Consent Please complete both (1) and (2): (1) Consent is given for (insert patient name) .. to receive a dental examination, including radiographs (if required), to be provided by a dentist from the DHSV Domiciliary Dental program. Consent is given for the release of medical history and medication information about this patient to the Dental Health Services Victoria Domiciliary Dentistry program. (2) Name: ...... Signature: ..... Consent given by: The Patient The Person Responsible Date: .././.....

E. Current Dental Needs: I would like a dental checkup I have a toothache Yes / No Yes / No I only want emergency treatment for my main dental problem Yes / No Yes / No Yes / No I want all of my dental problems treated (a complete course of dental care) Yes / No I have a problem with my dentures

Do you have any remaining natural teeth?

Other dental need (please describe):..... Where applicable, how can the dental team communicate best with you?...... F. Dental History: Have you been seen at the Royal Dental Hospital of Melbourne before? Yes / No If yes, when?....................................... Have you been seen by the Domiciliary Dental Unit before? Yes / No If yes, when?......................................................... ......

Have you had a general anaesthetic for dental treatment before? Yes / No If yes, when and where?................................ Please turn over.

Page 3

Domiciliary Dentistry Program Dental Health Services Victoria Level 4, 720 Swanston Street, Carlton Vic 3053 Tel: (03) 9341 1000 Fax: (03) 9341 1214

G. Medical Questionnaire
A dental examination cannot be provided until this medical questionnaire is completed by your medical practitioner. Patients Surname . Given Name ..
Current Medication Please specify current prescription and over the counter medications. You may attach a drug chart photocopy or Webster pack details if necessary. Drug allergies: Yes / No (If yes please describe) . Medical History Please specify past and current medical conditions and hospitalisations (please note any bleeding problems, history of rheumatic fever and prosthetic implants). Please attach another list or Medical History Summary sheet if available. ... Do you normally make house calls for this patient?..................................................................................... Do you consider this patient to be house bound? If yes, please specify why?................................................................................................................... Will this patient need antibiotic cover if any extraction of teeth is required? Yes / No Yes / No Yes / No

Is there anything else regarding this patients condition which you feel is relevant to the provision of their dental treatment? (E.g. Dysphagia / swallowing, physical, behavioural problems, communication / comprehension difficulties) Medical Practitioner Details Medical Practitioners name (please print): Dr. ... Practice Address: .. Telephone Number: Provider Number:... Medical Practitioners Signature: Date: ___ __/_____/____________ Thank you for completing this questionnaire. If you have any questions please contact us on 9341 1000.

Page 4