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State of Illinois Department of Public Health PROOF OF SCHOOL DENTAL EXAMINATION FORM To be completed by the parent (please print): Student s Name: Address: Last Street First Middle City Birth Date:
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How to fill out dental exam and waiver

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How to fill out a dental exam and waiver:

01
Start by obtaining the necessary forms. Most dental offices will provide a dental exam and waiver form at the time of your appointment. If not, you can usually find them on the dental office's website or request them beforehand.
02
Carefully read through the form to understand the information required. The dental exam and waiver form typically consist of sections asking for personal information, medical history, and consent.
03
Begin by filling out the personal information section, which may include your name, address, contact details, and date of birth. Ensure that all the information is accurate and spelled correctly.
04
Move on to the medical history section. This part is crucial as it allows the dentist to have a comprehensive understanding of your health background. Provide details of any existing medical conditions, allergies, medications you are taking, and previous dental treatments you have received.
05
If applicable, indicate if you have dental insurance and provide details of your insurance provider. This portion helps the dental office in processing insurance claims on your behalf.
06
Read through the consent section carefully. This section usually covers matters such as treatment authorization, acknowledgement of potential risks associated with dental procedures, and agreement to the financial responsibilities involved.
07
Review the completed form to ensure all the information provided is accurate and legible. If in doubt about any section, don't hesitate to ask the dental office staff for clarification.

Who needs a dental exam and waiver:

01
Anyone seeking dental treatment or services from a dental office will typically need to fill out a dental exam and waiver form. This includes new patients, as well as existing patients undergoing specific procedures or regular check-ups.
02
Minors under the age of 18 may require a parent or legal guardian to complete the dental exam and waiver form on their behalf. This ensures that the responsible adult understands and consents to the dental treatment being provided.
03
Dental exam and waiver forms may also be required for individuals participating in dental research studies or clinical trials, as they need to provide informed consent and disclose their medical history.
04
It is important to note that the specific requirements regarding dental exam and waiver forms may vary depending on the dental office and the nature of the dental treatment being sought. It is always best to confirm with the dental office directly if you have any questions or concerns about the need for a dental exam and waiver.
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Dental exam and waiver is a form that must be completed by individuals to either report their dental examination results or provide a waiver if unable to undergo a dental exam.
All individuals are required to file a dental exam and waiver form.
To fill out the dental exam and waiver form, individuals must provide their personal information, dental exam results, or submit a waiver if applicable.
The purpose of the dental exam and waiver form is to ensure that individuals are maintaining good oral health and receiving necessary dental care.
The dental exam and waiver form must include personal information, dental exam results, and any necessary waiver information.
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