Get CA Oral Health Assessment Form 2010
Keep this with your child s immunization record yellow card January 2007 Calif Dept. of Education Oral Health Assessment Form California law Education Code Section 49452. 8 states your child must have a dental check-up by May 31 of his/her first year in public school* A California licensed dental professional operating within their scope of practice must perform the check-up and fill out Section 2 of this form* If your child had a dental check-up in the 12 months before he/she started school ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child fill out Section 3. Section 1 Child s Information Filled out by parent or guardian Child s First Name Last Name Middle Initial Child s birth date Address Apt. City ZIP code School Name Teacher Grade Child s Sex Male Female Child s race/ethnicity White Black/African American Hispanic/Latino Asian Native American Multi-racial Other Native Hawaiian/Pacific Islander Unknown Parent/Guardian Name Section 2 Oral Health Data Collection Filled out by a California licensed dental professional IMPORTANT NOTE Consider each box separately. Mark each box. Assessment Date Yes No Visible Decay Present Treatment Urgency No obvious problem found Early dental care recommended Caries without pain or infection Caries Experience fillings present Urgent care needed pain infection swelling or soft tissue or child would benefit from sealants or further evaluation lesions Licensed Dental Professional Signature CA License Number PRINTED Provider Name/Clinic Name Phone Fax Section 3 Waiver of Oral Health Assessment Requirement To be filled out by parent or guardian asking to be excused from this requirement Please excuse my child from the dental check-up because Check the box that best describes the reason I am unable to find a dental office that will take my child s dental insurance plan* My child s dental insurance plan is Medi-Cal/Denti-Cal Healthy Families Healthy Kids None I cannot afford a dental check-up for my child. I do not want my child to receive a dental check-up* Other reasons my child did not get a dental check-up If asking to be excused from this requirement Signature of parent or guardian The law states schools must keep student health information private. Your child s name will not be part of any report as a result of this law. This information may only be used for purposes related to your child s health. If you have questions please call your school* Return this form to the school no later than May 31 of your child s first school year. 8 states your child must have a dental check-up by May 31 of his/her first year in public school* A California licensed dental professional operating within their scope of practice must perform the check-up and fill out Section 2 of this form* If your child had a dental check-up in the 12 months before he/she started school ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child fill out Section 3. Section 1 Child s Information Filled out by parent or guardian Child s First Name Last Name Middle Initial Child s birth date Address Apt. .
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