Microsoft Word - UMFS-TFC Child Dental Exam Form



Treatment Foster Care ServicesReport of Dental Examination Name of Child: ________________ Date of Exam: ________________ DOB: ________________This is to certify that ________________ had a dental examination on the above date. Dental cleaning was performed Yes NoAdditional dental work performed:

Recommendation include:

Signature of dentist or designee ___________________Date_______Address: ______________________________________________________________________________ ................
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