School Entry Immunization Record School Year

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Preschool Screening by Public Health Services for 2015-2016
On the day your child comes to school for registration or a welcome to school event, Public Health Services
will be present for dental and vision assessments. Please stop at both stations that day, even if your child is
already followed by a dentist or eye doctor.
If your child is being followed regularly for a known eye concern, please visit the nurse and sign a
“Request for Vision Information from Doctor” form. This will help us to track the prevalence of
eye problems in Nova Scotia.
Seeing a Dentist Regularly:
Public Health recommends you take your child for his/her first dental check-up by his first birthday,
to assess risk for cavities and answer your questions. Also take your child to a dentist if you see any white
or brown spots on his/her teeth, or if he/she injures a tooth. This is free through MSI until your child is 13
years old.
Seeing an Eye Doctor Regularly:
Public Health recommends that you take your child to an eye doctor for his/her first assessment by age one,
and then again for a comprehensive eye exam by age three. This is free through MSI until your child is 10
years old.
If you will not be with your child when he/she visits the school to see Public Health, please sign
the consent below for your child to be screened by public health staff.
Oral Health Assessment: A Public Health Dental Hygienist examines the health of your child’s teeth and
gums by looking with a flashlight into his/her mouth.
 Yes, I consent for my child to participate in the oral health assessment provided by Public Health
Services.
 No, I do NOT consent for my child to participate in the oral health assessment provided by Public Health
Service.
Enhanced Vision Screening Program: A Public Health Nurse or Licensed Practical Nurse tests your child
for
The ability to see details from a distance using an eye chart.
Depth perception and the ability of the eyes to work together using 3D glasses and images.
Checking the area around the eyes for redness, drainage, puffiness, etc.
 Yes, I consent for my child to participate in the vision screening provided by Public Health Services.
 No, I do NOT consent for my child to participate in the vision screening provided by Public Health Services.
By completing and signing this form, I confirm that I am the parent/legal guardian with legal
authority to make decisions regarding Vision and Oral Health Assessments for
____________________________________.
Child’s Name
Parent/Guardian_____________________________(Please print)
Signed ____________________________________
Date_______________________
Updated June, 2014

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