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Dental Program Forms

Pink "School Preventive Services Form”

What is the School Preventive Services Form?

Peel Public Health Registered Dental Hygienist and Certified Dental Assistant visit Peel elementary schools to provide dental screenings. A dental screening is a visual check of a child’s mouth and teeth.

During a dental screening a Peel Public Health Registered Dental Hygienist and Certified Dental Assistant found that your child would benefit from preventive services.

Peel Public Health is offering FREE preventive services in partnership with your school. Services that may be provided 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

Why did my child get this type of form?

A form was sent home to inform you that your child may benefit from preventive dental services.

This form is given only to children who have had a dental screening at an elementary school.

What should I do with this form?

If you would like your child to participate in preventive services at school:

  1. Complete all sections on the reverse side and sign
  2. Return the completed form to the school using the envelope provided by the date that is on the form

If your child cannot attend the preventive services at school:

  1. Call Peel Public Health at 905-799-7700, ext. 5622 (tell us you have a pink form or C4 form)

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Revised: September 01, 2016

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