MCPS Form 525-17
January 2017
Dental Health Form
Montgomery County Department of
Health and Human Services
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
INSTRUCTIONS: School health professionals review student health information, including dental health, when students enroll in
school. When health problems are identified, school health professionals assist students and parents/guardians in accessing appropriate
health services, including dental care.
Please complete Section I of this form and ask your child’s dentist or dental hygienist to complete and sign Section II of this form. Return
the completed form to the health room at your child’s school.
Help in locating a dentist/dental hygienist may be obtained by contacting the Maryland State Dental Association at www.msda.com.
If you do not have access to dental care, please contact the school nurse in your child’s school.
SECTION I: To be completed by Parent/Guardian
Name of Student Student ID
Name of School Date of Birth Grade
SECTION II: To be completed by the Dental office.
This is to certify that I have examined the teeth of ________________________________________________________________________
and:
o All necessary dental work has been completed.
o Treatment is in progress.
o No dental work is necessary.
Further recommendations ______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Name of Dentist/Dental Hygienist Telephone
Signature of Dentist/Dental Hygienist Date Signed
Address Fax Number
PLEASE RETURN THIS FORM TO THE HEALTH ROOM AT YOUR CHILD’S SCHOOL.
