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Dental Health

Non-Participation Dental Form

SCHOOL DENTAL SCREENING NON-PARTICIPATION FORM

Please complete and submit this form at least 2 business days before the school dental screening begins.

Required fields are marked with asterisks (*)

YYYY-MM-DD

Add additional child(ren)

Reason for Exclusion:



*

The personal information on this form is collected under the authority of the Health Protection and Promotion Act, 1990 s.5. The information will be used for the purposes of program planning and service delivery. Documents are maintained pursuant to the Municipal Freedom of Information and Protection of Privacy Act, 1991 and the Personal Health Information Protection Act, 2004. Questions regarding the collection, use and disclosure of personal information should be directed to the Office of the Privacy Officer, Simcoe Muskoka District Health Unit, 15 Sperling Drive, Barrie ON L4M 6K9, (705) 721-7520 or 1-877-721-7520.

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