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2019-04-02T16:14:21+10:00
Consent Form
Title
*
Mr.
Mr.
Mrs.
Ms.
Name
*
First
Last
Resident's DOB
*
Date Format: DD slash MM slash YYYY
Facility Name
*
Resident's section / Room No
*
Your Full Name
*
Your Email
*
Your Phone Number
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Does the resident hold a DVA gold card?
No
Yes
Please provide Card number
Do you give permission for the resident named to take part in an oral assessment by Advance Oral? (Cost $42)
*
No
Yes
Please sign here (Click and press to sign)
*
Date
Date Format: MM slash DD slash YYYY
Advance Oral offers other services. These would be carried out 1-4 weeks after the assessment. Please tick any that you would like to receive:
Select All
Denture - permanent Identification (incl complementary clean) $25 per denture
Denture - professional clean $25 per denture
Hearing Aid - permanent identification $12 per hearing aid
Spectacles - permanent identification $12 per spectacles