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:
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
Format: (000) 000-0000.
Should be Empty:

HCS Student Dental Health Form