District of Columbia Department of Health
899 North Capitol Street, N.E.
Washington, DC 20002 Telephone: (202) 442-5955
Fax: (202) 442-4795
E-mail: [email protected]
Website: https://dchealth.dc.gov/
Available from the website.
This form, to be completed by parents and oral health professionals, provides space to write
information about children over age 3 to give the student's child care facility or school. Part I, for
parents to fill out, is for the child’s name, age, birthdate, grade, and child care facility or school name. Part II, for an oral health professional to fill out, is for the child’s oral health status and
insurance status. Space for the oral health professional’s name, signature, and stamp, as well as
the date of the oral examination, is included. It is available in Amharic, Chinese, English, French, Korean, and Vietnamese.
