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PARENT INTERVIEW DOCUMENTS/OUTREACH

PARENT INTERVIEW DOCUMENTS/OUTREACH. Migrant Dental Screenings Child’s Last Name First Name MI Date of Birth (month/day/year) Sex: M F Address City State Zip Telephone ( ) - Please Circle All that Apply: Yes , I want my child to have a Dental Screening

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PARENT INTERVIEW DOCUMENTS/OUTREACH

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  1. PARENT INTERVIEW DOCUMENTS/OUTREACH

  2. Migrant Dental Screenings Child’s Last Name First NameMI Date of Birth(month/day/year) Sex: MF AddressCity StateZipTelephone ( ) - Please Circle All that Apply: Yes, I want my child to have a Dental Screening Yes, I also want my child to have a Fluoride treatment No, I do not want my child to have a Dental Screening or Fluoride If your child has other treatment needs we will contact you to try to schedule a follow up visit. A parent or guardian must be present at that follow up visit in order to do any dental procedures. Signature of Parent or Legal GuardianDate ************************************************************************ ApellidoNombreMI Fecha de Nacimiento(Mes/Día/Ano) Sexo: MF DirecciónCiudad EstadoCódigo PostalTeléfono( ) - Porfavor marque lo pertinente: Si, Yoquieroque me niño/a obtanga un chequeo dental (realizadopor dentist o higienista) Si,Yoquieroque mi niño/a obtengatratmiento de fluoruro No, Yo no quieroque me niño/a obtengaun chequeo dental e fluoruro Si suniñonecesitatratamientoadicionalnoscomunicaremos con ustedparahacerunacita de seguimiento. Un padre?madre/tutor necesitaráacompañar el/la niño/a a la citaparaobtenerserviciosdentales. Firma Padre/Madre o TutorFecha

  3. RECORD OF STUDENT HEALTH HISTORY Student Number: / / / / / / / / Student Name: Last First MI Birthdate: / / / Please indicate with a check mark in the appropriate column whether the child has had the illnesses listed below.

  4. ESPEDIENTE DE LA SALUD MEDICA DEL ESTUDIANTE Numero del Estudiante: / / / / / / / / /Fecha de Nacimiento: / / Nombre del Estudiante:Apellido Primer NombreInicial En la columnaapropiadapor favor marque lasenfermedadesque ha tenido el estudiante.

  5. (THIS FORM IS ELECTRONICALLY GENERATED FROM THE SUMMARY FORM)

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