Parent or caregiver

First Name *

Last Name *

Residential Address *

Street *

Suburb *

Postcode *

Child

First Name *

Last Name *

Date of Birth *

Does your child identify as Aboriginal and/or Torres Strait Islander? *

Preferred Phone Number *

Email Address (optional)

Preferred Dental Clinic *

This clinic is temporarily not accepting appointment requests - please select another clinic.

Alternatively, please visit childdentalbenefitssa.com.au for other options using the Child Dental Benefits Schedule (CDBS).

Preferred time for us to call you

Morning (9:00am to 12:00pm)Afternoon (12:00pm to 4:00pm)

We will aim to contact you at the specified time.

Any other comments

For security please complete the check below *

Please note:

A ‘No Caller ID’ will appear when the clinic phones you.
The information will not be used for any other purpose and will be confidentially disposed of after three months.
Please read our Privacy Policy & Disclaimer for further information.

Please select an available clinic

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