Clinical Program Enrolment

(* Indicates Required Field)
Section 1
General information required
Enrolment Consent*
- I wish to enrol in the Oral Health Promotion Program that will extend over 3 years, beginning with the birth of my baby, and ending soon after she / he reaches age 3 years and has had the second clinical dental examination to determine the health status of her / his primary (‘baby’) teeth.
Name of the participating expectant mother*
First Name Last Name
Expected date of my baby’s birth*

Day
Month
Year
Hospital where my baby is expected to be born*
Section 2
Personal information required for clinical database and delivery of healthcare products to participating families.
Residential Address*
Street Address Address Line 2 Suburb State Postcode
Postal Address
(If different from Residential Address)

Street Address Address Line 2 Suburb State Postcode
Email Contact*
Telephone Contact*
(Landline / Mobile)
Name of your General Dental Practitioner*
The Dental Practitioner you consult for periodic dental ‘checks’.
Date of most recent dental check*

Day
Month
Year
Will other children will be residing with mother and newborn?*
- Yes
- No
Residing Children Names & Ages*
Please enter their names and their expected ages (years & months) when baby sibling is expected to be born.
Section 3
Optional information sought for our Confidential clinical database.
(PLEASE NOTE: there is NO OBLIGATION on the part of Program participants to complete all or some parts of this Section.)
Mother's Date of Birth

Day
Month
Year
Mother's Occupation
Do you work Full-time or Part-time?
- Full-time
- Part-time
Do you use a xylitol-containing chewing gum regularly?
- Yes
- No
PLEASE NOTE:
All of the information to be entered in Sections 1 to 3 will be considered as Highly Confidential and will NOT be shared with any person, business, or Research Institution / research group. It will remain stored in a database accessible only by the Director of the Oral Health Promotion Program and his Senior Research Associate responsible for maintenance of the database.
Please complete the security check
Name
This field is for validation purposes and should be left unchanged.

Section 1

Section 2

Section 3

PLEASE NOTE:

Participate in the Health Promotion Program & Clinical Study