Community Dental Service Referral

A free dental service is available to provide care and advice from 0-18 years of age.

Please fill out all the fields below:

Child's First Name

Child's Middle Name(s)

Child's Family Name(s)

Also Known As





Street Address (Include suburb and postcode if known)

Home Number

Mobile Number

Other Contact (Name)

Other Contact's Phone

Email Address (Parent/Guardian)

Brother's/Sister's Name/s and Date of Birth

Brother's/Sister's Name/s and Date of Birth

Brother's/Sister's Name/s and Date of Birth

Medical Practice

Current School/Preschool

Is your child eligible to receive free health care in the NZ public health system?





For more information on eligibility please visit www.moh.govt.nz/eligibility (this link will open a blank page) or contact 0800 825 583

Ethnicity:
Which ethnic group does this child belong to? Tick the space/s that apply
NZ European
Maori
Samoan
Cook Island Maori
Tongan
Niuean
Chinese
Indian

Other, please state



Last updated: Tuesday, May 10, 2016

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