• Oral Health Assessment Form

  • California law (Education Code Section 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 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. If you are unable to get a dental check-up for your child, fill out Section 3.

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

  • Child’s Sex*
  • Child’s race/ethnicity*

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

  • IMPORTANT NOTE: Consider each box separately. Mark each box.

  • Assessment Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Caries Experience (Visible decay and/or fillings present)*
  • Visible Decay Present*
  • Treatment Urgency*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Section 3: Waiver of Oral Health Assessment Requirement

  • To be filled out by parent or guardian asking to be excused from this requirement

  • Please excuse my child from the dental check-up because: (Check the box that best describes the reason)
  • My child’s dental insurance plan is:

  • If asking to be excused from this requirement:

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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.

  • Return this form to the school no later than May 31 of your child’s first school year.
    Original to be kept in child’s school record.

  • Should be Empty: