Parent or caregiver

First Name *

Last Name *

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

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