A preventive oral health is available through the Ridgeway R-V and Missouri Department of Health and Senior Services. This program is offered to all children in the state of Missouri, including those who receive regular dental care. A licensed dental professional will provide an oral screening for your child and a trained volunteer will apply a thin coating of fluoride varnish to your child's teeth as a preventive measure against tooth decay. This thin coating will be applied twice a during the school year. Fluoride varnish has been proven to be safe and effective in preventing and reversing small ares or early tooth decay. This preventive program also includes a free toothbrush and oral health information. ** This service does not replace a regular dental cheek-up, which is recommended at least once a year.** * Yes, I want my child to recieve a dental screening and two varnish applications. Yes, I want my child to have the dental screening, but I do NOT want my child to recieve the fluoride varnish.. No, I do not want my child to participate in this program.
Student's Name * First Last
Teacher's Name
Grade
Has your child ever had a serious health problems? * Yes No
If yes please explain:
Does your child have any allergies? Yes No
If yes please list:
Parent Signature *
Date * / MM / DD YYYY

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