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Gr. 9 Dental 2021-22
Please complete the following form to Opt In/Out of State Mandated Dental Screening for Grade 9 Students.
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* Indicates required question
Student Last Name
*
Your answer
Student First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Parent/Guardian First Name
*
Your answer
School Dental Screening
*
My child receives regular dental care. Please DO NOT Screen.
My child receives regular dental care, but I would still like them screened by the hygienist.
Required
Dentist Name
Your answer
Date of Last Oral Exam (If known)
MM
/
DD
/
YYYY
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