Dental Caries Risk Assessment

Please correct the errors described below.

Cavities are the leading chronic health condition in children. Please answer the following questions to help us determine whether your child is at high risk for dental problems

For Parent or Guardian to complete:

“If my child is referred to a dentist for follow up care, I give my permission to share this information with the dentist.”

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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