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Dental Outreach Program

School dental screening consent form

School screenings are FREE and intended for ALL children PK-12th grade

School: South Haven Schools USD #509

Student First Name*

Answer required for "Student First Name"

Student Last Name*

Answer required for "Student Last Name"

Parent/Guardian Information

Guardian First Name*

Answer required for "Guardian First Name"

Guardian Last Name*

Answer required for "Guardian Last Name"

Phone*

Number Required

Dentist Name

Answer required for "Dentist Name"

A dentist HAS seen my child in the last six (6) months*

Answer required for "A dentist HAS seen my child in the last six (6) months"

YES

It is important for your child to see the dentist at his or her office every six (6) months for regular checkups to prevent tooth decay.

I give my permission for my child to have a FREE dental screening done by a local dentist during the school day*

Answer required for "I give my permission for my child to have a FREE dental screening done by a local dentist during the school day"

YES

Parent/Guardian Signature*

Signature Required

Dentist Office Use Only

Untreated Decay:______________

Treated Decay:________________

Sealants:____________________

Treament Code:_______________

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"