Monongalia County Schools Dental Form
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1MONONGALIA COUNTY SCHOOLS DENTAL FORM
Child’s Name:
Date of Birth:
Gender:
Address:
Phone:
Dental Needs:
Treatment Required:
Cleaning
Restoration
Exam
Pulp Therapy
Fluoride Treatment Received
Extraction
Sealant Administration
Other ________________________________
No Problems Noted
Oral conditions prior to today’s visit: (Please indicated on diagram all that applies)
Missing Tooth: ( X )
Decayed Tooth: ( = )
Filled Tooth: (
)
UR/UL
DATE
TOOTH #
LR/LL
SURFACE
DESCRIPTION OF WORK
NEXT SCHEDULED APPOINTMENT
Provider Signature required for validation:
Date of Service: _________________________________________
Name of Clinic: _________________________________________
_______________________________________________________
Signature of Dental Provider
Please return this form to:
Monongalia County Schools
Head Start Office
1433 Dorsey Avenue
Morgantown, WV 26501
Fax: (304) 291-9324
Dental Form 1.2013
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Parent category: Medical