DENTAL EXAMINATION PERMISSION FORM

Date: _________________

Dear Parent/Guardian:

In accordance with the School Health Law all children of school age in the Commonwealth, (I) upon original entry into school, (ii) while in 3^rd grade, and (iii) while in 7^th grade, shall be given a dental examination by a school dentist.

You are encouraged to have this dental examination completed by your family dentist using the attached private exam form. If you prefer, our school dentist will be completing these exams on ____________________. If any defects are noted upon examination, you will be notified so you may contact your family dentist. If you wish to be present, during the examination, please contact the school nurse.

Please complete the bottom portion of this form and return it to school as soon as possible. If you have any questions, please do not hesitate to call me.

________________________________

School Nurse/School Nurse Practitioner

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I, ______________________________________, hereby consent to the dental examination of my son/daughter in school, and I further acknowledge that I have read and understand the contents of this form.

or

______ I will have is mandated dental examination completed by our family dentist and return the Private Dental form to the school.

_______________________________ ______________________________

Print Name of Son/Daughter and Grade Parent/Guardian Signature and Date