Online Enrolment for New Zealand Citizens

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Enrolment can take up to 4 weeks to process. To prevent delays in enrolling your child(ren) into Bee Healthy Regional Dental Service, please complete the online enrolment form in full.

If you need help to complete the online enrolment please call 0800 TALK TEETH (0800 825 583) or email dental@huttvalleydhb.org.nz

Is your child a New Zealand Citizen?

[_] Yes - please continue filling out the form below. If no, click here to complete the online enrolment for non-citizens.

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 (3 letter, 4 digit number in your child's Well Child booklet)
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 Doctor or Medical Practice *
Does your child have any medical conditions?
Yes

No
If yes, please list 0/500 Words
Consent

This consent will remain valid while your child continues to receive dental care provided by Bee Healthy Regional Dental Service on a mobile clinic or at a dental hub. Consent can be withdrawn at any time by contacting Bee Healthy Regional Dental Service: 0800 TALK TEETH (0800 825 583)
Please select
I AGREE for my child to be enrolled with Bee Healthy Regional Dental Service for regular dental check-ups.
I AGREE for my child to receive fluoride varnish application and teeth cleaning.
I AGREE to the use of dental x-rays for detecting decay and other conditions when indicated.
I understand that should any preventative coating, fillings or extractions be required, my consent for these will be requested before these are provided.
I declare that my child is a New Zealand Citizen.

Online Enrolment for New Zealand Citizens

Enrolment can take up to 4 weeks to process. To prevent delays in enrolling your child(ren) into Bee Healthy Regional Dental Service, please complete the online enrolment form in full.

If you need help to complete the online enrolment please call 0800 TALK TEETH (0800 825 583) or email dental@huttvalleydhb.org.nz

Is your child a New Zealand Citizen?

Personal details of your child

Parents or Guardian Contact Details

Child's Medical History

Consent

Dental Care for Children