Editing previous response:

Please fix the highlighted areas below before submitting.

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

Answer Required

Parent/Guardian Information

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

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
Parent/Guardian Signature*
Signature Required

Sign this form

By pressing “Sign Form,” you are agreeing to signing this form electronically.
Signature *
Type to sign
Draw your signature


Dentist Office Use Only

Untreated Decay:______________

Treated Decay:________________


Treament Code:_______________

Confirmation Email