School Dental Referral Form printable pdf download

School Dental Referral Form

Name________________________________________________________________

Address_______________________________________________________________

School _______________________________________________________________

Grade _____________________________ Date _____________________________

TO THE PARENTS:

Our school has a health program that is designed to improve, protect and promote the

health of each child. As part of this health program we strongly urge you to take your

child to a dentist of your choice at least twice a year for a dental examination and

whatever treatment may be necessary. When the examination and treatment are

completed, this form will be returned to school.

TO THE DENTIST:

Check one of the following statements before signing this card:

Teeth were found in satisfactory condition

All necessary dental work has been completed.

Signature of Dentist__________________________________ Date _________________

1/09

School Dental Referral Form