Dental Screening Permission 2023-2024
Consent form for a simple, visual dental screening by the school dental hygienist in the school nurse's office. 

The dental hygienist will:
  • Use a mouth mirror to conduct the visual screening
  • Provide toothbrush, toothpaste (and floss as indicated) along with oral hygiene instruction
  • Send a summary of the screening home with the student
  • Contact the parent/guardian to discuss the summary of the screening (as needed)
  • Offer some in-school prevention procedures (example: fluoride and sealants) as needed
  • Help parents/guardians find a dentist for their child (as needed)
  • Mail a summary of the screening finding to the student's regular dentist (if applicable)
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Email *
Student's Name *
Student's Date of Birth *
MM
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DD
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YYYY
Student's Grade *
Student's Homeroom Teacher or Advisory *
I give permission for my child to be screened by the school dental hygienist.  

 *
Required
Parent/Guardian Name for Electronic Signature *
Date *
MM
/
DD
/
YYYY
Parent/Guardian's email address *
Parent/Guardian's best phone number during the day *
How long has it been since your child has seen a dentist? *
Required
Please indicate your dental insurance. *
Required
Does the student have a regular dentist? *
Required
If "YES" the student has a regular dentist, please list the name of the dentist/dental practice (or type in "not applicable") *
If the student goes to Timberlane Dental, please indicate the location: *
Required
Optional: Share any dental concerns or dental questions you have about the student:
Thank you for completing this online permission form.  Once you review your answers, please be sure to hit the "SUBMIT" button to send the form.
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