Waiver of Oral Health Assessment Requirement

California Department of Public Health

July 2021 – Page 1 of 2

Please fill out this form if you need to excuse your child the oral health assessment requirement.

Sign and return this form to the school where it will be kept confidential.

Section 1: Child’s Information (Filled out by parent or guardian)

Child’s First Name: Last Name: Middle Initial: Child’s Birth Date:

MM – DD – YYYY

Address: Apt.:

City: ZIP code:

Teacher: Grade: Y

ear child starts

kindergarten:

Y Y Y

Parent/Guardian Last Name:

Child’s Gender:

 White  Native American

 Black/African American  Multi-racial

 Hispanic/Latino  Native Hawaiian/Pacific Islander

 Asian  Unknown

 Other (please specify)

School Name :

Parent/Guard ian First Name:

Child’s Race /Ethnicity:

Continued on Next Page

Male Female

Clear Form

California Department of Public Health

July 2021 – Page 2 of 2

Section 2: To be filled out by parent or guardian ONLY IF asking to be excused from this

requirement

Please excuse my child from the assessment because (check the box that best describes the reason):



I cannot find a dental office that will take my child’s dental insurance plan. My child’s dental

insurance plan is:

 Medi-Cal

 Healthy Kids  None

 Other:__________________________________________________________



I cannot afford an assessment for my child.



I cannot find the time to get to a dentist (e.g., cannot get the time off from work, the dentist does not

have convenient office hours).



I cannot get to a dentist easily (e.g., do not have transportation, located too far away).



I do not believe my child would benefit from an assessment.



Other (please specify the reason not listed above for why you are seeking a waiver of this

assessment for your child):

__________________________________________________________________________

If asking to be excused from this requirement:

MM – DD – YYYY

____________________________________________________ ____________________________________

Signature of parent or guardian

Date

The law states schools must keep student health information private. Your child's name will not be part

of any report as a result of this law. This information may only be used for purposes related to your

child's health. If you have questions, please call your school.

Return this form to the school no later than May 31 of your child’s first school year.

Original to be kept in child’s school record.

Covered California