Tooth Taxi Interest
Parents & Legal Guardians
Mobile Dental Clinic Notice

The Dental Foundation of Oregon (DFO) whose mission is to improve oral health for Oregon’s
children will be visiting our school with their mobile dental van, the Tooth Taxi, within the next few
weeks.

*The Tooth Taxi is staffed by dental professionals and offers a range of dental services including
cleanings, fillings and oral health education for FREE.*

   1. If you would like your child seen by Tooth Taxi staff, please fill out this online form as soon as possible (should only take a minute). Once completed, a Tooth Taxi Packet will be sent home with your child.
   2. Completed Tooth Taxi Packets must be returned to the school before any
screening or treatment can begin.

Students that have returned the completed Tooth Taxi Packet will be screened by the Tooth
Taxi dentist, the week of May 9th-13th. Priority of treatment is based on:  
  - students in pain
  - students that have no dental insurance
  - students that have never been to the dentist
  - students with OHP who are not seeing a dentist.

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Email *
I am interested in having my child (children) participate, please send home a complete packet for me to fill out (a complete packet will need to be completed for each child): *
Student #1 Name *
Student #1 Teacher *
Student #2 Name
Student #2 Teacher
Student #3 Name
Student #3 Teacher
Parent/Legal Guardian Name (acting signature) *
Parent/Legal Guardian Phone # *
Today's Date *
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The Tooth Taxi Mobile Dental Van
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