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Dental Health

Non-Participation Dental Form

SCHOOL DENTAL SCREENING NON-PARTICIPATION FORM

Please complete and submit this form at least 2 business days before the school dental screening begins.

Required fields are marked with asterisks (*)

* Child’s First Name:

* Child’s Last Name:

* Child’s DOB:

YYYY-MM-DD

* Child's Grade:

* Name of School

Add additional child(ren)

Please indicate first/last name, DOB and grade for each additional child

* Parent/Guardian (full name):

* Email Address:

* Verify Email Address:

Reason for Exclusion:

Have an Insurance Plan
Child was just at the dental office
COVID-19 Concerns
Other

Please Specify:

I understand that by checking this box my child will NOT have a dental screening done by a Registered Dental Hygienist.

The personal information on this form is collected under the authority of the Health Protection and Promotion Act, 1990 s.5. The information will be used for the purposes of program planning and service delivery. Documents are maintained pursuant to the Municipal Freedom of Information and Protection of Privacy Act, 1991 and the Personal Health Information Protection Act, 2004. Questions regarding the collection, use and disclosure of personal information should be directed to the Office of the Privacy Officer, Simcoe Muskoka District Health Unit, 15 Sperling Drive, Barrie ON L4M 6K9, (705) 721-7520 or 1-877-721-7520.

Search our Website

Dental Health

Non-Participation Dental Form

SCHOOL DENTAL SCREENING NON-PARTICIPATION FORM

Add additional child(ren)

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