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This information is for a dental screening and fluoride varnish only, NOT a complete dental exam.

NOPAYMENT is required from you for this program. Participation in this program will not change your child’s primary oral healthcare provider. Please fill out one form for each child who attends this school.

California law (Ed Code 49452.8) states your child must have a dental check-up by May 31 of his/her first year in public school. A California licensed dental professional operating within his/her scope of practice must perform the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2.

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

Child’s First Name: / Last Name: / Middle Initial: / Child’s birth date:
Address: / Phone:
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______□ Unknown

What health insurance does your child have?

Medi-Cal My Health LA Private None Not sure

Has your child been to the dentist in the last 6 months? Yes No In the last 12 months? Yes No

Which of the following beverages did your child drink in the last 7 days?

Tap waterBottled water Juice Soda Sports or energy drinks

How often does your child brush his/her teeth?

Less than once /day Once/day Twice/day More than twice/day Unsure

Your school has partnered with a licensed dental provider who will come to the school and perform the mandated dental check-up for free to students. Please read the information below and check the appropriate box to indicate whether you would like for your child to receive this service: I consent and agree to have a licensed dental provider look at my child's teeth and have fluoride varnish applied. I also allow the results of the screening and my child’s school attendance data to be collected and shared as a part of an evaluation to improve this program. I understand that only the dental information collected may be shared amongPROVIDER’S NAME,LAUSD, and associated approved research data collectors, my dentist or referring dentist in coordination of dental care for my child.I give permission for my child to be photographed and/or videotaped for publicity purposes for PROVIDER’S NAME, The DentaQuest Foundation, LAUSD and The L.A. Trust for Children’s Health.

Yes I want my child to receive a dental screening and fluoride varnish.

No I DO NOT want my child to receive a dental screening and fluoride varnishand will complete the mandated oral health screening outside of school and return this form by May 31.

State the reason ______

Parent/Guardian's Signature: Date:

______

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

IMPORTANTNOTE: Consider each box separately. Mark each box.

Assessment Date: / Caries Experience
(Visible decay and/or fillings present)
□ Yes □ No / 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 CA License Number Date

The law states schools must keep student health information private. Your child's name will not be part of any report as a result of this law. This information may only be used for purposes related to your child's health. If you have questions, please call your school.

Form to be collected at each school no later than May 31 of the child’s first school year. Original to be kept in child’s school record.