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