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For people with a disability
Sign up to get the support you deserve
First Name
Email
Year of Birth
Last Name
Phone
Postcode
If you are completing this on behalf of someone else please enter your name, contact details and relationship to the individual:
Disability categories
*
Required
Intellectual disability
Acquired brain injury
Person with disability in Aged Care
Complex Medical Condition
Complex Communication Needs
Other (type in answer)
Other disability
If you saw a dentist in the past 12 months was it a:
Special Needs Dentist
General dentist – private clinic
General dentist – public or community clinic
General dentist – dental hospital
An oral health therapist
A different type of dental specialist
Other
I have not seen a dentist in the past 12 months
I am not sure
If you have seen a dentist in the past 12 months why did you attend?
I had pain
I was told I had to go
I needed a check up
I needed a clean
I needed a filling
I had to have a have a tooth out
I cannot remeber
Other
I have not seen a dentist because:
I had a negative experience
I am too scared
They do not understand my issues
There have been access issues
They cannot cater to my needs
Not sure
Do you have a Support Plan or Behaviour Support plan that could help the dentist work better with you?
Do you need support for decision making?
Yes and I have a guardian
Yes and I do not have a guardian
No
Do you have access and support needs?
I would like to talk to the oneonetwelve team before being matched to a dental practitioner:
Yes
No thanks
I would like my name displayed on the day of the event:
Yes
No thanks
To assess your eligibility for this program, please tick all the boxes that are relevant:
I receive a disability support pension
I receive support from NDIS
None of the above. A member of our team will contact you to find out more information
Apply
Thank you! We’ll be in touch.
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