Bubbles Dental School Health form

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 his 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 Name:*

First NameMiddle NameLast Name
Address*

Apt.

Street Address Line

CityState / Province

Postal / Zip Code
School Name*
Teacher*
Grade*
Child’s Sex*

MaleFemale
Parent/Guardian Name:*
Child’s race/ethnicity*

WhiteBlack/African AmericanHispanic/LatinoAsianNative AmericanMulti-racialNative Hawaiian/Pacific IslanderUnknownOther
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:*

MonthDayYear
Date
Caries Experience (Visible decay and/or fillings present)*

YesNo
Visible Decay Present*

YesNo
Treatment Urgency*

No obvious problem foundEarly dental care recommended (caries without pain or infection; or child would benefit from sealants or further evaluation)Urgent care needed (pain, infection, swelling or soft tissue lesions)
Licensed Dental Professional Signature*

Clear
CA License Number*
Date*

MonthDayYear
Date
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.I cannot afford a dental check-up for my child.I do not want my child to receive a dental check-up.Optional: other reasons my child could not get a dental check-up
My child’s dental insurance plan is:

Medi-Cal/Denti-CalHealthy FamiliesHealthy KidsNoneOther
If asking to be excused from this requirement:
Signature of parent or guardian *

Clear
Date*

MonthDayYear
Date
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.
Original to be kept in child’s school record.
Should be Empty:

Oral Health Assessment Form

Section 1: Child’s Information (Filled out by parent or guardian)

Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)

Section 3: Waiver of Oral Health Assessment Requirement