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 First Name:
Child’s birth date:
□ Male □ Female
□ White □ Black/African American □ Hispanic/Latino □ Asian
□ Native American □ Multi-racial □ Other___________
□ Native Hawaiian/Pacific Islander □ Unknown
Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)
IMPORTANT NOTE: Consider each box separately. Mark each box.
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)
□ I am unable to find a dental office that will take my child’s dental insurance plan.
My child’s dental insurance plan is:
□ Medi-Cal/Denti-Cal □ Healthy Families □ Healthy Kids □ Other ___________________ □ None
□ I cannot afford a dental check-up for my child.
□ I do not want my child to receive a dental check-up.
Optional: other reasons my child could not get a dental check-up: If asking to be excused from this requirement: ____________________________________________________
Signature of parent or guardianDate
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.