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The following immunizations were received on the dates shown:
Student’s Name: ____________________________ ________________________________ ________________ Physician’s Signature Date _______________________________ __________________________________ Street Address City, State, Zip Student’s Name: ____________________________ ________________________________ ________________ Physician’s Signature Date _______________________________ __________________________________ Street Address City, State, Zip
Name:__________________________________ D.O.B.: ___________________ District: Hamilton CityAddress:_____________________________ Phone:__________ Date Seen By Dentist:_____________ School: St. Ann Catholic School Grade: ____ Teacher: ____________ Date Returned: ______________DENTAL EXAMINATION REPORT Has your child had a dental examination by your family dentist within the last six months? If not, will you arrange for such an examination as soon as possible? In either case, please have the dentist fill in and sign below, then return this from to the school. This is to certify that I have examined and found the condition checked below: ___ No dental defects ___ Treatment has been started ___ Dental defects which were present ___ Treatment is needed but no provision is made for it. have been completed cared for. Date: _____________ Signature of Dentist: ____________________________________________ It is not possible to take my child to the family dentist for examination or treatment. Date: _____________ Signature of Parent: _____________________________________________ |
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