Dental Health Solutions for Children
North Clackamas Family Support Center
6031 SE King Road, Milwaukie, Oregon 97222
503-353-6096 office | 503-353-5664 fax
www.nclack.k12.or.us
REFERRAL FORM
Use this form to refer a student for services to the North Clackamas School District’s Dental
Health Solutions for Children program
Return this form to us via:
o Email: hartsonm@nclack.k12.or.us - - OR - - mastersoma@nclack.k12.or.us
o Fax: 503-353-5664
Date of Request: ___________________________
Student Name: _______________________________________________________________
School: _____________________________________________________________________
Teacher: ______________________________ Grade: ________
Does the student have dental insurance: _____OHP
Student ID: ___________
_____Other Dental Insurance
Contact Information:
Parent’s Name: ______________________________________________________________
Relationship to Student: ________________________________________________________
Phone Number(s): ____________________________________________________________
Email: ______________________________________________________________________
Is the student having dental pain? _____Yes _____No
Does the student have: _____swelling/abscess
_____broken tooth/teeth
Reason for referral:
Name of person referring student: ________________________________________________
Relationship to student: ________________________________________________________
Phone number(s): ____________________________________________________________
Revised 3/31/2015