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CONSENT FORM

smilogy Aged Care has been engaged to conduct Oral Health Assessments onsite for residents of _____________ on dd/mm/yy.

While visits can be arranged for individual residents on request/subject to their individual oral health requirements, by participating in this facility-wide annual assessment program, the cost of the assessment is reduced.

The cost for this service is $42.00 and includes a comprehensive written report detailing current conditions, suggested care and treatment recommendations. The cost is payable by the resident.

Where the resident is a Veteran Affairs Gold Card holder, this service is free.


To take advantage of this program, please complete the form below or contact us with any questions on 02 9490 2579 or by clicking the Get in Touch button above.0411234022

 

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If you prefer to download a form to complete, please return it to _________ by dd/mm/yy.

Payment by Electronic Funds Transfer

Account Name: Smilogy Pty Ltd
BSB 082167
Account No. 974194253
Please send receipt to agedcare@smilogy.com.au

*Please note:

Credit card will not be charged until the assessment has been conducted.

A receipted invoice will be emailed to your nominated email address on completion for your records. Contact agedcare@smilogy.com.au to update your contact information at any time.