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Kentucky Dental Screening/Examination Form for School Entry
Kentuckylaw,KRS156.160(i),
requiresproof of a dentalscreeningor examinationby a Dentist,DentalHygienist,Physician,RegisteredNurse,Advanced
RegisteredNursePractitioner,
or PhysicianAssistant This evidenceshall be presentedto the schoolno labr than January1 of the fiIst yearthat a five (5)
or six (6) yearold is enrolledin publicschool.
Student Name:
Birth date:
I
(fiEckone)
Test Type:
First
I
Middle
Gender:
f]ouate
It
remate
D Screening
I Exam
Parentor
RelatiorFhp
Name
Address:
PhoneNumber:
City
Screene/s Name:
David Sperow, D.M.D
Screene/s
Address:
311 S. Main St
Lawrenceburg, KY 40342
School:
Dateof Enrollment
I
I
PhoneNumber
502-839-3424
ScreenirEDate:
Screener'sSignatrre:
UntreatedDecay: (oEckor€)
TreatedDecay:
(oEckore)
Professional
Affiliation:(Pleasecheckone)
I ONountreated
cavities
I OtrtotreatedcaVties
I t UnfeaeOcaVties
! 1 Treatedcavities
tr Dentist
I DentalHygienist
I enysician
Assistant I LHORegistered
Nurse wtn xPS Smiles
trairirE
Innrup
Pattem of Early Childhood
Cavities: (ctpckore)
TreatmentUrgency: (o€ck
ore)
I O No EarlyChildhoodCaMties
I
I t eanyChildhood
Cavties
Present
I
I
I enysician
Comments:
OruoobVousoroblem
t eartydentalcareneeded
2 Refenalfor UrgentCare
NOTE:Commentrcquiredif marked.
OH-12 (rev, 1f2il11)