PORTSMOUTH SCHOOL DEPARTMENT

PRE-ENTRANCE DENTAL FORM

Child’s Name: ______________________________________ Grade: _____________

Child’s Address: _________________________________________________________

As of January 1990, the state of Rhode Island recommends a pre-entrance dental exam. Please have your dentist examine your child and return this form to the school nurse as soon as possible.

Name of Dentist: _________________________________________________________

Dentist’s Address: ________________________________________________________

Dentist’s Phone No.: ______________________________________________________

Report and comments:

‡ All necessary work has been completed _________________________________

‡ Treatment is in progress _____________________________________________

‡ No treatment is necessary ____________________________________________

Signature of Dentist: ____________________________________ Date:_____________

ADM-08-01