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Home / Demo Dentist Form

Demo Dentist Form

Step 1 of 9

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Please select an option from the list below.*
- I would like to make an appointment for myself
- I would like to make an appointment for a family member
- I am referring my client to Star Health Dental
- I am a Star Health staff member referring a client
Are you 12 years or younger?*
- Yes
- No
Are they 12 years or younger?*
- Yes
- No
Do you have a Health Care Card or Pension Card?*
- Yes
- No
Do they have a Health Care Card or Pension Card?*
- Yes
- No
Are you Aboriginal and/or Torres Strait islander?*
- Yes
- No
Are they Aboriginal and/or Torres Strait islander?*
- Yes
- No
Are you a refugee?*
- Yes
- No
Are they a refugee?*
- Yes
- No
Have you previously attended Star Health dental service?*
- Yes
- No
Have they previously attended Star Health dental service?*
- Yes
- No
Important
Star Health provides an affordable private dental service. Details on pricing can be obtained by following the below link:

https://starhealth-bhn.studiomoso.com.au/services-2/fees/
Would you like to proceed with booking an appointment?*
- Yes
- No
Please proceed back to our Request a Service page.

Star Health Program
Please select the client's Program Area*
- Community care
- ICT
- Int clinical care
- Mental Health AOD
- Organisation Support and Development
- Strengthening Community
Your Name*
Your direct phone number
Star Health Email Address*

Your Organisation
Type of Organisation*
- Aboriginal Torres Strait Islander Service
- Allied Health
- Disability Support Service
- Early years setting
- GP Practice
- Homeless Support Service
- Hospital Outpatient Service
- Maternal Child Health Nurse
- Mental Health Service
- Midwife
- Parent/Carer
- Practice Nurse
- Preschool
- Primary School
- Secondary School
- Smoking Cessation Service
- Supported Residential Services
- Other

Your Details
Organisation/Agency Name*
Your department
Contact Name*
Position
Contact Information
Phone Number*
Fax Number
Email

Your Details
Name*
Your given name Your surname
Your date of birth*
Their Details
Name*
Their given name Their surname
Their date of birth*
Address
Address*
Your street address Your suburb Your postcode
Address*
Their street address Their suburb Their postcode
Contact Information
Your phone number*
Their phone number*
Email

Please include your email address if you would like to receive a copy of the referral
Interpreter
Is an interpreter required?*
- Yes
- No
Is an interpreter required?*
- Yes
- No
Interpreter Language*
Interpreter Language*

Circumstances
If they are 13 years or older, please tick the boxes below to indicate their current circumstances*
- They have a valid pension card
- They have a valid health care card
- They are a refugee or an asylum seeker who has resided in Australia for less than 5 years
- They are 18 years or younger and their parent has a valid health care card or pension card
- They are 18 years or under and in out of home care provided by Children Youth and Families Division of the Department of Human Services
- They are 18 years old or under and a youth justice client in custodial care
- None of the above

Additional Information
Please tick the boxes below to indicate if any of the following apply to your client. They are:
- A child or young person (0 years to 18 years of age)
- A disability client (supported by a letter of recommendation from your case manager or staff of special development school)
- A mental health client (supported by a letter of recommendation from your case manager)
- A refugee or asylum seeker (supported by copayment form from registered organisation)
- An Aboriginal or Torres Strait Islander
- HIV+
- Homeless or at risk of homelessness (supported by copayment form from case manager)
- Pregnant
Please tick the boxes below to indicate if any of the following apply to you. I am:
- A child or young person (0 years to 18 years of age)
- A disability client (supported by a letter of recommendation from your case manager or staff of special development school)
- A mental health client (supported by a letter of recommendation from your case manager)
- A refugee or asylum seeker (supported by copayment form from registered organisation)
- An Aboriginal or Torres Strait Islander
- HIV+
- Homeless or at risk of homelessness (supported by copayment form from case manager)
- Pregnant
Please tick the boxes below to indicate if any of the following apply to the person the appointment is for
- A child or young person (0 years to 18 years of age)
- A disability client (supported by a letter of recommendation from your case manager or staff of special development school)
- A mental health client (supported by a letter of recommendation from your case manager)
- A refugee or asylum seeker (supported by copayment form from registered organisation)
- An Aboriginal or Torres Strait Islander
- HIV+
- Homeless or at risk of homelessness (supported by copayment form from case manager)
- Pregnant
They are:
Important Note
Please have their case manager complete this Application for Co-Payment Exemption form and have your family member bring it to their appointment
Important Note
Please have your case manager complete this Application for Co-Payment Exemption form and bring it to your appointment
Important Note
Please complete this Application for Co-Payment Exemption form and have your client bring it to their appointment

Reason for the appointment
Please tick the reason(s) for the appointment.*
- Regular dental check
- Bleeding gums
- Complex medical condition
- Denture issue
- General concern
- Mouth pain or toothache
- Swelling
Please select a maximum of two items.
Important
Mouth pain and toothache can require urgent attention. Please urgently contact Dental Admin on 9525 1300 to set up an appointment.
Important
Swelling can require urgent attention. Please urgently contact Dental Admin on 9525 1300 to set up an appointment.

Location
Please select the preferred location for treatment*
- Prahran: 240 Malvern Rd, Prahran 3181
- South Melbourne: 341 Coventry St, South Melbourne 3205
Additional Information
Please include any comments or additional Information
Please prove you are human by selecting the Star.

Important information

You will be contacted by a member of the Dental team to confirm this referral within 2 working days
Please bring a list of the medications you / the patient is currently taking to the appointment.
Please bring any dental x-rays you / the patient is currently taking to the appointment.
If you are unable to attend your appointment, please ring 9525 1300 giving at least 24 hours’ notice of your cancellation.
If you are a referring agency, your client will be contacted to make an appointment with the Star Health Dental team.

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