Oral Health Screening Consent And Recommendations printable pdf download

Oral Health Screening Consent and Recommendations

(Please Print)

This section to be completed by parent, guardian or child’s representative:

Child’s Name: _________________________________________________ Date of Birth: ______________

Parent’s/Guardian’s/Representative’s Name: ___________________________________________________

Relationship to Child: _____________________________________________________

I understand that by signing this form I am consenting for the child named above to receive a basic oral health

assessment, or dental screening. I understand this screening is only a very basic evaluation and does not take the

place of a thorough dental examination. I would need to secure the services of a dentist in order for my child to

receive a complete dental examination necessary to establish and maintain oral health.

I also understand that receiving this dental screening does not establish any new, ongoing or continuing doctor-

patient relationship. I am free to establish such a doctor-patient relationship for my child in the future with the

dentist performing this screening or another dentist of my choice. Further, I will not hold the dentist or those

performing this assessment responsible for the oral health consequences or results should I choose NOT to follow

the recommendations listed below.

________________________________________________________________________ Date: _____________

Signature of Parent/Guardian/Representative

This section to be completed by the dental professional providing the assessment:

Dear Parent or Guardian,

Beginning January 1, 2007, California law requires that all children entering public school for the first time, at either

kindergarten or first grade, receive an oral health assessment by a dental professional before May 31st of their first

school year. Today, I completed a dental screening for your child and below are the results of that evaluation.

Dental screenings only find obvious dental problems and are meant to identify children who need dental care. No X-

rays were taken and this screening does not replace a thorough dental examination by a dentist.

Below are the results of the screening and my recommendation:

_____

Your child has no obvious dental problems but should receive routine examinations by a dentist.

_____

Your child appears to have some dental problems which should be evaluated by a dentist. Please make an

appointment at your earliest convenience so that your child can receive a complete examination. Your

dentist will determine, what, if any, treatment is needed.

_____

Your child has some dental problems which appear to need immediate care. Contact a dentist as soon as

possible for a complete examination.

Additionally, I have explained the risks of NOT proceeding with the recommendation provided and have fully

responded to the questions posed to me by the parent/guardian/representative.

___________

__________________________________________________________ Date:

Dental Professional’s Signature

Developed by the California Dental Association and the California Society of Pediatric Dentistry to assist dental professionals

providing dental screenings as a public service.

November 2006

Oral Health Screening Consent And Recommendations