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Illinois Department of Public Health PROOF OF DENTAL EXAMINATION FORM To be completed by the parent (please print): Students Name: LastFirstMiddleBirth Date:Address: Streetcar zip CodeTelephone:(Month/Day/Year)/Name
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How to fill out proof of dental exam

01
Schedule an appointment with your dentist.
02
Inform your dentist that you need a proof of dental exam form filled out.
03
Attend your appointment and undergo the necessary dental examination.
04
Ask your dentist to complete and sign the proof of dental exam form.
05
Make a copy of the completed form for your records and submit the original to the relevant party.

Who needs proof of dental exam?

01
People who are required to provide proof of dental exam for various purposes such as school enrollment, employment, or insurance purposes.
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Proof of dental exam is a certification or documentation that verifies an individual has undergone a dental examination, typically required for compliance with certain regulations or guidelines.
Individuals who are required to file proof of dental exams often include students in certain educational programs, employees in specific jobs, or patients undergoing certain medical procedures that necessitate a dental evaluation.
To fill out proof of dental exam, one must provide the necessary personal information, the name of the dental professional, the date of the examination, results of the examination, and any recommendations made by the dentist.
The purpose of proof of dental exam is to confirm that an individual has received appropriate dental care and to ensure any dental health issues are identified and addressed before they escalate.
Information that must be reported includes the patient's name, date of birth, date of the dental exam, findings from the exam, and the dentist's signature.
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