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Male
Female
Evergreen Elementary School
Grants Pass High School
Illinois Valley High School
Lorna Byrne Middle School
Selection
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Yes
No
Dentist Name:
Yes
No
OHP Advantage
OHP Capitol
OHP Open Card
OHP Willamette
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Fluoride varnish application (As need indicates)
Dental screening on molar(s)
Dental health screening
A thin preventative coating applied to chewing surface grooves to keep bacteria out.
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Next
Please check the number of months since your child last saw a dentist
3-6 Months
6-9 Months
Over 12 Months
Never Seen
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www.siskiyouhealthcenter.com
Demographics
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Select Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White/Caucasian
More than one race
Selection
Select Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Selection
Select Primary Language
English
Spanish
Sign Language
Other
Selection
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