From: Subject: NYS Dental Health Certificate - Shenendehowa CSD Date: Wed, 27 May 2009 10:10:23 -0400 MIME-Version: 1.0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.shenet.org/district/policy_and_forms/DentalHealthCert.htm X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 NYS Dental Health = Certificate - Shenendehowa CSD

Shenendehowa Central = School=20 District

NYS=20 Dental Health Certificate-

 

Parent/Guardian:  =20 New York State law (Chapter 281) permits schools to request a = dental=20 examination in the following grades: school entry, K, 2, 4, 7, = & 10.=20 Your child may have a dental check-up during this school year to = assess=20 his/her fitness to attend school.  Please complete Section 1 = and take=20 the form to your dentist for an assessment.  If your child = had a=20 dental check-up before he/she started the school, ask your dentist = to fill=20 out Section 2.  Return the completed form to the school's = medical=20 director or school nurse as soon as possible. =

Section=20 1. To be completed by Parent or Guardian (Please=20 Print)

Child=92s=20 = Name:           &n= bsp;           &nb= sp;      =20 = Last          &nbs= p;            = ;    =20 =             &= nbsp;           &n= bsp;      First    &nbs= p;            = ;            =             &= nbsp;           &n= bsp;           &nb= sp;           &nbs= p;=20 Middle

 

Birth=20 Date:         =20 /           = /

           =    =20 Month    =20 Day      Year   =

Sex: =F0 Male

       =20 =F0 Female

Will=20 this be your child=92s first visit to a=20 dentist?        =F0 Yes    = =F0 No          &nbs= p;            = ;            =             &= nbsp;           &n= bsp;           &nb= sp;  =20

School: =20 Name  

 

Grade

Have=20 you noticed any problem in the mouth that interferes with your = child=92s=20 ability to chew, speak or focus on school activities?  = =F0 Yes  = =F0 No  =20

I=20 understand that by signing this form I am consenting for the child = named=20 above to receive a basic oral health assessment. I understand this = assessment is only a limited means of evaluation to assess the = student=92s=20 dental health, and I would need to secure the services of a = dentist in=20 order for my child to receive a complete dental examination with = x-rays if=20 necessary to maintain good oral health.

 

I also=20 understand that receiving this preliminary oral health assessment = does not=20 establish any new, ongoing or continuing doctor-patient = relationship.=20 Further, I will not hold the dentist or those performing this = assessment=20 responsible for the consequences or results should I choose NOT to = follow=20 the recommendations listed below.

 

Parent=92s=20 = Signature______________________________________________________________&n= bsp;=20 Date

Section=20 2. To be completed by the Dentist

I. The Dental Health = condition=20 of _______________________________ on _________________  = (date of=20 exam) The date of=20 the exam needs to be within 12 months of the start of the school = year in=20 which it is requested.   Check=20 one:

=7F Yes, The student = listed above=20 is in fit condition of dental health to permit his/her attendance at the public=20 schools.

=7F = No, The = student=20 listed above is not in fit condition of dental health to permit=20 his/her = attendance=20 at the public schools.

NOTE: Not in fit = condition of=20 dental health means that a condition exists that interferes with a = student's ability to chew, speak or focus on school activities = including=20 pain, swelling or infection related to clinical evidence of open=20 cavities.  The designation of not in fit condition of dental = health=20 to permit attendance at the public school does not preclude the = student=20 from attending school.

Dentist=92s name and = address=20 (please print or=20 = stamp)           &= nbsp;           &n= bsp;           &nb= sp;           &nbs= p;=20 Dentist=92s Signature

 

 

Optional Sections=20 - If=20 you agree to release this information to your=20 child=92s school, please initial here. =20 =             &= nbsp;           &n= bsp;           &nb= sp;     

 II. Oral Health = Status (check=20 all that apply).           = ;            =     =20

=F0 Yes  = =F0 No   = Caries=20 Experience/Restoration History =96 Has the child ever had a = cavity=20 (treated or untreated)?  [A filling (temporary/permanent) OR = a tooth=20 that is missing because it was extracted as a result of caries OR = an open=20 = cavity].           = ;   =20

=F0 Yes  = =F0 No   = Untreated=20 Caries =96 Does this child have an open cavity?   = [At least =BD=20 mm of tooth structure loss at the enamel surface. Brown to = dark-brown=20 coloration of the walls of the lesion. These criteria apply to = pits and=20 fissure cavitated lesions as well as those on smooth tooth = surfaces. If=20 retained root, assume that the whole tooth was destroyed by = caries. Broken=20 or chipped teeth, plus teeth with temporary fillings, are = considered sound=20 unless a cavitated lesion is also present]. 

=F0 Yes  = =F0 No   = Dental=20 Sealants Present    

Other problems=20 = (Specify):_______________________________________________________________= ________________

 

III. Treatment Needs = (check=20 all that apply)

=F0  No obvious = problem.=20 Routine dental care is recommended.  Visit your dentist=20 regularly.

=F0  May need = dental=20 care.  Please schedule an appointment with your dentist as = soon as=20 possible for an evaluation.

=F0  Immediate dental care = is=20 required.  Please schedule an appointment immediately with = your=20 dentist  to avoid problems.