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Health Services We Fund

Dental / Oral Health

Adolescent Dental Service - On-line Enrolment

Adolescents are encouraged to enrol with a dentist who holds a contract with their District Health Board to receive treatment under the government funded dental benefits.  Enrolment forms are also available from the School Dental Therapist for Year 8’s or by contacting the Adolescent Dental Coordination Service on 0800 ITS FREE or 0800 487 3733.

To enrol with the Adolescent Dental Service, please complete the form below and click on the 'Submit' button once completed:

Adolescent Dental Service On-line Enrolment Form
 Contact Details:
 First Name:
 Middle Name:
 Last Name:
 Address:
 Telephone Number:
 Email Address:
 
 Personal Details:
 Date of Birth:  
 Male or Female (please tick): Male Female
 
 Which ethnic group do you belong to?
 (please tick)
 		 New Zealand European Tongan
New Zealander Niuean
Maori Chinese
Samoan Indian
Cook Island Maori  
Other (such as Dutch, Japanese, Tokelauan)
    Please state:
   
 
 Other Details:
 Are you (please tick):  
 In Year 8?
 
 In Secondary School/College?
 What Secondary School will you be
 attending or do you attend?
 		  
 Have you left School?
 
 Dentists Details:
 Name of Chosen Dentist:  
 Address of Chosen Dentist:
 		  
   

By submitting (or sending) this form, you have stated that you wish the above dentist to be your dental provider.  You also agree to the sharing of clinical information between local District Health Boards, Ministry of Health and, if required, a new dental provider.

 

 

 

Published:  30-Nov-2006  |  Website enquiries:  Regional Coordinator