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When the Tooth Mobiles (mobile dental clinics) visit your school, the dental program staff will bring copies of these forms. It is not necessary for you to download the forms for your class, but they are available here for your review, or if a child needs a replacement form. Please contact the site coordinator if you have any questions about these forms.
Dental Program Forms |
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Clinical Forms |
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| This WHITE form needs to be completed for the child and signed by a parent/guardian before an intake exam, x-rays, or treatment can be provided. Treatments the program can provide include: fillings, root canals, extractions, cleanings, and dental emergency treatment. | |
| Parents who do NOT want their children screened by the dental program must sign and return this form. | |
| This PINK form informs the child’s parent that a free dental screening was conducted in the school. It indicates that the dentist did NOT find any visible decay. | |
| This YELLOW form indicates that the child was not screened by the dental program. | |
BLUE- Your Child may have a cavity in a baby tooth |
This BLUE form informs the child's parent that the child may have a cavity in a baby tooth that the dentist thinks will fall out in a few months. |
Teacher Forms |
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A Teacher's Aid! download here |
Explains the dental screening process that precedes a visit from the Tooth Mobiles. |
| Explains the consent form return incentive program for teachers and schools. | |
| Allows photographs of children or adults to be used in St. David's publications. | |
| A list of local resources families can contact to see if they are eligible for dental care. | |
