Oral Health Assessment/waiver Request Form
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2Oral Health Assessment/Waiver Request Form
Oral health assessments that have happened within the 12 months before your child enters
school also meet this requirement. If you cannot take your child for this assessment, you
may be excused from this requirement by filling out Section 3 of this form.
Section 1
To be completed by the parent or guardian
Child’s First Name:
Child’s birth date:
Last Name:
Middle Initial:
Address:
Apt.:
City:
ZIP code:
Child’s Gender:
School Name:
Teacher:
Grade:
□ Male
□ Female
Child’s race/ethnicity:
Parent/Guardian Name:
□ White
□ Black/African American
□ Hispanic/Latino
□ Asian
□ American Indian
□ Alaska Native
□ Native Hawaiian/Pacific Islander
□ Multi-racial
□ Unknown
Section 2
Oral Health Data Collection
To be completed by the dental professional conducting the assessment
Assessment
Visible caries
Visible caries present:
Treatment Urgency:
□ Yes
□ No obvious problem found
Date:
and/or fillings
□ No
□ Early dental care
present:
□ Yes
recommended
□ No
□ Urgent care needed
______________________________________________________________________
Dental professional’s signature
Date
Original to be retained in child’s school record.
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