Community Dental Appointments and Referrals

If you, your child, or a client of your service, would like to access dental treatment through Peninsula Health, please read through the below information and complete the form.

Who can use Community Dental Services?

Peninsula Health’s Community Dental program provides dental services to all members of the community either through our public clinics or private clinics. If you would like more information, please call (03) 9784 8184.

You should access dental treatment if:

• a child is over the age of two (2) years and has never had a dental check
• a child has a history of high consumption of sweet food and drinks
• you have complex medical conditions (for example, you are waiting for heart surgery, you have uncontrolled diabetes, you have cancer and are waiting for radiotherapy, you have renal failure or clients prior to starting bisphosphonate medication)

Community Dental Services referral form

I am(Required)

referring myself or a family member to Community Dental Services

referring a client to Community Dental Services

requesting a visit by the dental team for a FREE dental check-up and oral health education session

Referring Agency details

Referring Agency(Required)

Aboriginal Torres Strait Islander Health Unit

HARP

Oncology Department

Maternal Child Health Nurse

GP Practice

Practice Nurse

Midwife

Preschool

Parent/Carer

Allied Health

Early years setting

Primary School

Secondary School

Supported Residential Services

Smoking Cessation Service

Disability Support Service

Other –please state

Organisation / agency name:(Required)

Department:

Contact Name:(Required)

Position:

Telephone number:(Required)

Fax Number:

Email:

Confirmation of referral required(Required)

Yes

No

How would you like to receive confirmation?(Required)

Fax

Phone

Referrer Information

I am referring for a(Required)

Early Years CentrePrimary SchoolSecondary SchoolOther (please specify)

please specify(Required)

Organisation(Required)

Contact Person(Required)

Referrer Email

Referrer Phone Number(Required)

Client information:

If you do not live in Frankston or on the Mornington Peninsula and would like to find a community dental program closer to you contact Dental Health Services Victoria on 1300 360 054 or via their website

Address(Required)

Street Address City ZIP / Postal Code

Given Name:(Required)

Surname:(Required)

Date of birth(Required)

DD dash MM dash YYYY

Date format: DD-MM-YYYY.

Please tick the box to indicate your circumstances:

I am Eligible for Child Dental Benefits Schedule

I have a valid Health Care Card

I am 18 years or younger and my parent has a valid health care card or pension card

I have a valid Pension card

I am 0 up to 13 years old

I am 18 years old or under and a youth justice client in custodial care

I am 18 years or under and in out of home care provided by Children Youth and Families Division of the Department of Human Services

I am a refugee or an asylum seeker who has resided in Australia for less than 5 years

None of the above

Unfortunately you may not be eligible for treatment through the Community Dental Service. Please seek treatment through a private dentist or contact DHSV for advice on 1300360054

Phone(Required)

Secondary Phone

Please indicate whether any of the following categories apply to you:

Aboriginal and / or Torres Strait Islander

Child or Young Person ( 0 years to 18 years of age )

Pregnant

Homeless or at risk of homelessness

Refugee or asylum seeker

Mental Health client supported by a letter of recommendation from your case manager

Disability client supported by a letter of recommendation from your case manager or staff of special development school

Oncology client

Please select reason for referral(Required)

Its time for my regular dental check

Mouth pain or toothache

Bleeding Gums

Complex medical condition

Denture issue

General concern

Other

Other reason for referral

Comments

Please attach supporting documentation if applicable

Drop files here or Select files

Accepted file types: jpg, jpeg, png, doc, docx, pdf, Max. file size: 16 MB, Max. files: 2.

Please select preferred location for treatment(Required)

Hastings Community Dental
185 High St, Hastings 3915
PH: (03) 9784 8184

Rosebud Community Dental
1527 Point Nepean Rd, Capel Sound (Rosebud West) 3939
(rear of Rosebud Hospital)
PH: (03) 9784 8184

Frankston Community Dental
Frankston Integrated Health Centre
12-32 Hastings Rd, Frankston 3199
(next to Frankston Hospital)
PH:(03) 9784 8184

Community Health Dental Screening Consent Form
Please download the Community Health Dental Screening Consent Form and complete a consent form for each child. You will need to return the completed form prior to your scheduled dental visit.

School Principals click here for more information about school dental visits

I have printed this for my records (required before you can submit the form to us)

Yes

I have downloaded and printed the Community Health Dental Screening Consent Form for each child (required before you can submit the form to us).

Yes

Name

This field is for validation purposes and should be left unchanged.

Next steps

You will be contacted by a member of the Community Dental Services team to confirm your referral.

If you are a referring agency, your client will be contacted to make an appointment with the Community Dental team.