Dental Program Forms

• No Dental Care Required Notification Form
• Purple (Preventive Services Only Notification) or S-2
• Blue (Preventive Clinic Referral Form) & Healthy Smiles Ontario – Preventive Services Only Stream
• Pink (School Preventive Services Form)
• Healthy Smiles Ontario (HSO) Application Form
• Healthy Smiles Ontario – Parent Notification Form Emergency and Essential Services Stream (EESS)

Healthy Smiles Ontario – Parent Notification Form Emergency and Essential Services Stream (EESS)

What is the Healthy Smiles Ontario – Parent Notification Form Emergency and Essential Services Stream (EESS) Form?

This form is given to children whose dental screening (a visual check of a child's mouth and teeth) at school, or at a Peel Public Health Dental Screening Clinic, revealed a need for urgent dental treatment. 

Your child received this form to inform you that:

• Your child's dental screening revealed a dental condition(s) requiring immediate treatment by a dental provider.
• Peel Public Health provides the Healthy Smiles Ontario – Emergency and Essential Services Stream.
• Healthy Smiles Ontario – Emergency and Essential Services Stream pays for basic dental treatments for children under 18 years of age who need urgent dental care and meet the program's criteria.

What should I do with this form?

Option 1 – If you are able to pay for treatment:

• Complete Sections 1, 2, and 3A
• Take the Emergency and Essential Services Stream Form to your dentist.
• Ask your dentist to complete and sign Section 3B on the form.
• Mail the completed, signed form to the Peel Public Health address
  printed at the top of the form

Option 2 – If you are already Enrolled in Healthy Smiles Ontario:

• Complete Sections 1, 2 and 4A
• Take the Emergency and Essential Services Stream Form to your dentist.
• Ask your dentist to complete and sign Section 4B on the form.
• Mail the completed, signed form to the Peel Public Health address
  printed at the top of the form.

Option 3 – If you can't afford to pay for treatment:

• Complete Section 1, 2 and 5A, 5B, and 5C
• Sign Section 5 to request financial assistance.
• Mail the completed, signed form to the Peel Public Health address
  printed at the top of the form.

What will happen after I sign Section 5 and mail the completed form?

When your form has been processed, you will receive a welcome package and dental card in the mail.

What do you do once you receive your welcome package?

• If you have a dental provider, contact them to find out if they participate in Healthy Smiles Ontario.
• If you do not have a dental provider or yours does not offer Healthy Smiles Ontario services, ask family or friends to recommend a dental provider.
• If you still cannot find a dental provider contact Peel Public Health to help find you one.

 

 

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