Dental Requirements

  • Dental Requirement

    A dental health certificate shall be requested from each student at the same time that the health certificates are required, when entering grades kindergarten, two, four, seven and ten, as well as, all new entrants to the district. Each certificate shall describe the dental health condition of the student when the examination was made which shall not be more than twelve months prior to the commencement of the school year in which the examination is requested.

    Oral Health - Dental Assessment Form

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

    Child’s Name: __________________________________________________________ Child’s birth date: ____________________
    Address: __________________________________________________________________ City: ______________________________________________________________________ ZIP code: __________________________________________________________________ School Name: _______________________________________________________________ Teacher: ____________________________Grade: ______________

    Child’s Sex: □ Male □ Female
    Parent/Guardian Name: _______________________________________________________ Child’s race/ethnicity:
    □ White □ Black/African American □ Hispanic/Latino □ Asian
    □ Native American □ Multi-racial
    □ Native Hawaiian/Pacific Islander □ Other

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

    IMPORTANT NOTE: Consider each box separately. Mark each box.
    Assessment Date: ______________________________
    Assessment: ______________________________________________________________

    _________________________________________________________________________
    Visible Decay Present:
    □ Yes □ No

    Treatment Urgency: _________________________________________________________ □ No obvious problem found
    □ Early 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 License Number 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:
    If asking to be excused from this requirement:

    Signature of Parent or Guardian Date

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