Free Dental Sealant Permission Slip Form
Multnomah County School Dental Sealant Program
503-988-3905

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Your child's school has been chosen to participate in the Multnomah County School Dental Sealant Program. Dental Sealants are coatings put on the back of the teeth, and are a quick and easy way to prevent cavities. The screening, sealants and follow up care are FREE, and done by dental care professionals.
*If you wish to receive this service please continue with this form.
Name of Student: (Last, First, Preferred name) *
Student's Date of Birth (mm/dd/yy) *
Preferred language
Teacher
Child's grade *
School *
School District
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