Dental Health Certificate

Student Name*
Date Of Birth*
Date of Exam*

PLEASE NOTE:  Not in fit condition of dental health means that a condition exists that interferes with a student's ability to chew, speak or focus on school activities including pain, swelling, or infection related to clinical evidence of open cavities.  The designation of not in fit condition of dental health to permit attendance at the public school does not preclude the student from attending school.

Name
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