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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

Student Last Name*

Answer Required

Parent/Guardian Information

Guardian First Name*

Answer Required

Guardian Last Name*

Answer Required

Phone*

Number Required

Dentist Name

Answer Required

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

Answer Required

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

YES

Parent/Guardian Signature*

Signature Required

Dentist Office Use Only

Untreated Decay:______________

Treated Decay:________________

Sealants:____________________

Treament Code:_______________

Confirmation Email

Confirmation Email *

Email Required