[English Source Text]

All fees charged by the Dental Clinic are set by the Department of Human Services.

□          The cost for a general course of dental treatment is a minimum of $21 to a maximum of $84.

□          Patients are required to bring $21 to each visit payable before the appointment. However, each treatment item provided costs a set amount eg. Scale and clean $8.00; complex white filling on a back tooth $14.00. Payments are balanced at the completion of a course of treatment.

□          Any denture maintenance items )eg. Denture repairs or adjustments) are above the $84 maximum copayment

□          A new plastic denture costs approximately $50 and a metal frame denture costs approximately $150. The cost depends on the number of teeth and clasps that the denture has. Note that metal dentures are made only when there is a clinical requirement for one.

□          Referral to the specialist Endodontist for root canal treatment is an additional cost. This is up to $84 per tooth that is treated.

 

The clinician has discussed the information above with me. I have understood what has been discussed.

 

Patient Name ________________________ Signature __________________

 

Dentist Name _______________________ Signature ___________________

 

Date _____________________

_________________________________________________________________________

[Cantonese Target Translation]

 

公眾服務部（Department of Human Services）規定了牙科門診（Dental Clinic）的所有收費標準。

□          普通牙科治療收費標準為21澳元（最低）到84澳元（最高）。

□          病人應在每次就診之前支付21澳元治療費用。然而最後總費用將根據每項治療的費用來計算，比如除牙垢和清潔牙齒為8.00澳元，大牙複合填補修復為14.00澳元。所有費用將在治療完成後結算。

□          任何假牙修復服務（比如假牙修補和咬合調整）之費用都將超過84澳元（自費部分的最高標準）。

□          一副新塑料框架假牙大約需要50澳元，而一副金屬框架假牙大約需要150澳元。此費用將根據牙齒的數量和牙托上活動牙扣的數量來計算。注意，只有在臨床需要的情況下，才會製作金屬假牙。

□          若病人要求專業的牙髓醫師進行根管治療，則需支付額外費用。每顆牙齒治療費用最高為84澳元。

醫師已與我討論了上述情況。本人已理解醫師對收費情況之解釋。

 

病人姓名： ________________________ 簽名： __________________

醫生姓名： ________________________ 簽名： __________________

 

日期： ____________________