Adult waitlist

First Name: *

Last Name: *

Date of Birth *

Do you identify as Aboriginal and/or Torres Strait Islander? *

Postal Address *

Street *

Suburb *

Postcode *

Phone Number (mobile is preferred) *

Email Address *

Concession Card Type *

Customer Reference Number (CRN) (with letter) *

Concession Card (expiry date *

Do you have any natural teeth? *

Preferred Dental Clinic *

Please read the following & give your consent for SA Dental to check your current concession card before submitting this form.

I authorise:

SA Dental to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centrelink or Department of Veteran’s Affairs customer details and concession card status to enable the business to determine if I qualify for a concession, rebate or service.
The Australian Government Department of Human Services (the department) to provide the results of that enquiry to SA Dental.

I understand that:

The department will disclose personal information to SA Dental, including my name, address, payment and concession card type, and status to confirm my eligibility for public dental care.
This consent, once signed, remains valid while I am a customer of SA Dental unless I withdraw it by contacting SA Dental or the department.
I can get proof of my circumstances/details from the department and provide it to SA Dental so my eligibility for public dental care can be determined.
If I withdraw my consent or do not alternatively provide proof of my circumstance/details, I may not be eligible for the dental service provided by SA Dental.

Sign to agree *

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