Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 665 - CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
Subpart F - EYE EXAMINATION
Appendix E - Illinois Department of Public Health Dental Examination Waiver Form
Illinois Department of Public Health
DENTAL EXAMINATION WAIVER FORM
Please print:
Student's Name: LastFirstMiddle |
Birth Date: |
(Month/Day/Year) / / |
|
Address: StreetCityZIP Code |
Telephone: |
||
Name of School: |
Grade Level: |
Gender: MaleFemale |
|
Parent or Guardian: |
Address (of parent/guardian): |
I am unable to obtain the required dental examination because:
[] My child is enrolled in the free or reduced lunch program and is not covered by private or public dental insurance (medical assistance/ALL KIDS).
[] My child is enrolled in the free or reduced lunch program and is ineligible for public insurance (medical assistance/ALL KIDS).
[] My child is enrolled in medical assistance/ALL KIDS, but we are unable to find a dentist or dental clinic in our community that is able to see my child and will accept medical assistance/ALL KIDS.
[] My child does not have any type of dental insurance, and there are no low-cost dental clinics in our community that will see my child.
Signature |
___________________________ |
Date |
____________________ |