Dental Health Certificate Form
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1Dental Health Certificate - Optional
Parent/Guardian: Please complete Section 1 and take the form to your dentist/dental hygienist for an assessment. Request your
dentist/dental hygienist to fill out Section 2. Return the completed form to your child’s teacher as soon as possible.
Section 1. To be completed by Parent or Guardian (Please Print)
Last
First
Middle
Child’s Name:
Birth Date:
/
/
Sex:
Male
Will this be your child’s first visit to a dentist?
Yes
Female
No
Month
Day
Year
Name
School:
Grade
Section 2. To be completed by the Dentist/Dental Hygienist
I. Oral Health Status (check all that apply)
Yes
No Caries Experience/Restoration History – Has the child ever had a cavity (treated or untreated?
[A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR an open cavity].
Yes
No Untreated Caries – Does this child have an open cavity?
[At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the
walls of the lesion. These criteria apply to pits and fissure cavitated lesions as well as those on smooth tooth surfaces. If
retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary
fillings, are considered sound unless a cavitated lesion is also present].
Yes
No Dental Sealants Present
Yes
No Soft Tissue Pathology
Yes
No Malocclusion
II. Treatment Needs (check all that apply)
No need for Treatment
Urgent Treatment – abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
Restorative Care – amalgams, composites, crowns, etc.
Preventive Care – sealants, fluoride treatment, prophylaxis, mouthguard etc.
Other – periodontal, orthodontic treatments
Please note _____________________________________________________________
The Dental Health condition of ________________________ on _______________________ (date of exam) Check one:
Yes, The student listed above is in fit condition of dental health to permit him/her attendance at the public schools.
No, The student listed above is not in fit condition of dental health to permit him/her attendance at the public schools.
Dentist’s Name and Address (Please Print or Stamp):
Dentist/Dental Hygienist Signature:
Date of Exam:
/
/
* The dental health condition of the student when the exam is made and
the date of exam shall not be more than 12 months prior to the
commencement of the school year in which the exam is requested.
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