HCS Dental Health Form

HCS Student Dental Health Form

Please fill out on your device, then download and print the PDF to turn in.
Students are required to submit proof of dental exam to school by Dentist for Pre-Kindergarten, K, 2nd. , 7th and 12th grades.
Name of Student*
Student's Date of Birth*

MonthDayYear
Date
Student's Grade Level*
Student's Current School*
This is to certify that I have examined the above named student and these are the findings:

No dental work is necessary for student.Preventative Care: cleaning, exam, fluoride treatment, sealants, x-raysTreatment is in progress for studentAll necessary dental work has been completed
Is the student being referred to someone else for further dental work? If so, please provide the name of the doctor entity.
Date of last dental visit

MonthDayYear
Date
Further recommendations
Name of Dentist
Address
Fax
Phone
Should be Empty:

HCS Student Dental Health Form