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Dental Health

Child Care Dental Screening Participation Form

Please complete and submit this form at least 2 business days before our visit at your child’s preschool.

Please note required fields are marked with an * Asterisk.

YYYY/MM/DD (i.e., 2020/09/01)
E.g.
Name: Jane Doe
Date of Birth: 2020/04/06
E.g. Ferris Lane Community Daycare 49 Ferris Lane Barrie, ON
E.g. 15 Sperling Dr, Barrie, ON L4M 6K9
E.g. 705-721-7520
*

“The Health Unit collects personal information in the course of doing business. Personal information about you is collected directly from you or from the person acting on your behalf. Personal health information collected may include, for example, your name, date of birth, address, contact information, health card number, health history, and information you provide during visits or calls to the health unit.”