DCS 125 CPS (7/04). Report Of Medical/Dental Exam Fill and Sign
Illinois Dental Exam Form. Web state of illinois illinois department of public health tobecompletedbydentist: Health examination form, child :
DCS 125 CPS (7/04). Report Of Medical/Dental Exam Fill and Sign
Web the examination must have taken place within 18 months prior to may 15 of the school year. Web proof of school dental examination form. Web dental examination waiver form please print student’s name: Oral health status (check all that apply) £ yes. Illinois department of public health. Web this form must be submitted with your application. The current forms are linked. Web illinois department of public health proof of school dental examination form to be completed by the parent (please print): Illinois department of public health, division of oral. Web eye examination must be performed by a licensed optometrist within one year prior to the first day of school and submitted before october 15 of the school year dental.
A licensed dentist must complete the examination, sign, and date this proof of. Or submit an offi cial transcipt. Web dental examination waiver form please print student’s name: Please reference the illinois department of public health website to ensure you are using the current form. Illinois department of public health. Web this form must be submitted with your application. Dental sedation permit online application. Web state of illinois certificate of child health examination. Last first middle birth date: To be completed by the parent (please print): Web all dental hygienists must have a current illinois license to practice.
