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Request to decline school dental screening

Dental screening is important

Dental screening is provided each year in all elementary schools under Ontario Regulation 570, School Health Programs and Services, Health Protection and Promotion Act .

To identify dental problems that could lead to pain or infection and need to be treated by a dentist
To help families access needed dental treatment
To monitor the dental health of children in our community and use this information to plan programs and services

For more information about the school screening visit: kflaph.ca/SchoolScreening.

If you have questions about the school dental screening process, please contact us at 613-549-1232, ext. 1218. We are here to discuss your concerns and provide more information.

Decline school dental screening

If you do not want your child to be screened this school year, please submit this form at least three business days before your child's screening day. If it is less than three business days, please call us to notify us at least 24 hours prior to the screening day. If your child switches schools during the school year, it is your responsibility to notify us. One form must be completed for each student you wish not to be screened.

Today's date

Legal parent or guardian full name

Phone number

E-mail address

Child's first name

Child's last name

Child's date of birth

School name

Child's Grade

Decline request (choose one)

I wish to decline school dental screening for the current school year

I wish to decline school dental screening for the current school year and all future school years

Reason you are declining school dental screening (select one)

Child sees a dental provider on a regular basis

Child is nervous or anxious

I'm not interested in Public Health services

I want to know more about the dental school screening program. Please call me before screening is provided.

Prefer not to say

Other

If other, please specify

Collection of personal health information

Personal health information collected on this form is kept confidential and used to monitor local data, plan and provide local programs and services, case management, program administration, and program evaluation. You may withdraw your consent to provide additional health information at any time. Any questions about the collection and use of this information should be directed to the manager of dental health, KFL&A Public Health, 221 Portsmouth Ave., Kingston, Ontario or call 613-549-1232, ext. 1141.