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Dental Program Forms

Blue "Preventive Clinic Referral" Form and Healthy Smiles Ontario – Parent Notification Preventive Services Only Stream Form(HSO-PSO)

 

What is the Preventive Clinic Referral Form?

Our Preventive Clinic Referral Form and Healthy Smiles Ontario – Parent Notification Preventive Services Only Stream Form (HSO-PSO) is given to children whose dental screening (a visual check of the child's mouth and teeth) at a Peel Public Health Dental Screening Clinic revealed they qualify to receive preventive dental services from Peel Public Health.

Preventive dental services include: 

  • Dental Cleaning – a thorough cleaning of the teeth that cannot be achieved at home
  • Pit and Fissure Sealants – a plastic material that is placed on the chewing
    surface of the molars to prevent cavities
  • Professionally Applied Topical Fluoride – a gel applied to the teeth to prevent cavities

This form is given only to children who have had a dental screening at a Peel Public Health Dental Screening Clinic.

Your child may visit a Peel Public Health Dental Screening Clinic for a free screening if your child:

  • was not screened in their elementary school
  • is not yet in elementary school (i.e., preschoolers)
  • missed the elementary school dental screening
  • is in high school, or out of school and under 18 years of age

Why did my child get this type of form?

Your child received this form to inform you that your child qualifies to receive preventive dental care.

This form is given only to children who have had a dental screening at a Peel Public Health Dental Screening Clinic.

What should I do with this form?

Please DO NOT take this form to a dentist.

Complete the form front and back, including your child’s health history on the back of the form. 

Call Peel Public Health at 905-799-7700 to book an appointment for preventive dental services.

Bring your completed blue form with you to your child’s
Peel Public Health Preventive Dental Clinic appointment.

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Revised: January 14, 2016

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