Enrol online

Children with New Zealand citizenship or appropriate resident status are entitled to free oral health care until their 18th birthday.
Complete the form below to enrol your child with Bee Healthy Regional Dental Service.

Personal details of your child

Child's First Name *

Child's Family Name *

Gender *

Male
Female

Child's Date of Birth *

Street Address *

Suburb *

City *

Post Code *

NHI Number (this is a 3 letter, 4 digit number that can be found in your child's Well Child booklet) e.g. ABC1234

Child's Ethnicity 1 *

Child's Ethnicity 2 (optional)

Child's Ethnicity 3 (optional)

School your child attends or will attend *

Prefered Clinic *

Siblings Already Enrolled (include name and birth date)

0/500 Words

Parents or Guardian Contact Details

Your First Name *

Your Family Name *

Relationship to child

Home Phone

Mobile Phone

Email *

Alternative contact person (enter full name)

Relationship to child

Home phone

Mobile Phone

Child's Medical History

Name of Child's Doctor *

Doctors Address

0/500 Words

Does your child have any medical conditions? *

Yes
No

If yes, please list

0/500 Words

Consent

I agree for my child to be enrolled with the Regional Dental Service for dental checkups and receive procedures for the prevention of decay and gum disease including the application of fluoride, preventative coatings/fissure sealants and teeth cleaning.

Please select

Yes, I agree
No, I do not agree

I agree to the use of dental x-rays for detection of decay and other conditions

Please select

Yes, I agree
No, I do not agree

Personal details of your child

Parents or Guardian Contact Details

Child's Medical History

Consent

Dental Care for Children