Oral Health Forms

The Office of Head Start oral health forms are important records of a pregnant woman’s, pregnant person’s, or child’s dental visit. The forms provide information on dental home and current oral health status, and what oral health care services were delivered during the dental visit. These services include diagnostic and preventive services, counseling, restorative and emergency care, and referral to a specialist for care. The forms also record what oral health care services are needed and any information to share with others.

• Head Start Oral Health Form
  • Children
  • Pregnant Women and Pregnant People

  FAQs

  Are we required to use the Head Start oral health forms?

  No, Head Start programs are not required to use the Head Start oral health forms. Each Head Start program establishes a system to document the health services a pregnant woman or pregnant person or child receives. Head Start staff may use any form that works best for their program, either the forms provided here, state-mandated forms, or their own forms.

  Can we enter our Head Start program’s name and contact information electronically in the Head Start oral health forms?

  Yes. The electronic form is designed for Head Start staff to enter information into specific fields in the form. Staff can customize the forms with the Head Start program’s name, mailing address, phone and fax numbers, and e-mail address.

  For best results, download the forms to your computer and open them with Adobe Reader, which is available at no charge. Then you can customize the forms and save or print them.

  How do we share the form with dental offices?

  Head Start programs can share the form in multiple ways, including:

  • Giving the form to the parent of a child or a pregnant woman or pregnant person to bring to the dental visit
  • Mailing, faxing, or e-mailing the form to the dentist directly
  • Posting the electronic form on the Head Start program’s website for the dentist to download

  How can we explain to oral health providers how to use the Head Start oral health forms?

  A sample letter is available for Head Start staff to introduce the Head Start oral health forms to oral health providers. This letter can be customized with the Head Start program’s information.

  Should a new Head Start oral health form be used for each visit?

  Yes, each time a pregnant woman or pregnant person or child has a dental visit, an oral health provider should complete a new form. Once a form has been completed, mail a printed form to the Head Start program or e-mail an electronic form via a secure Internet connection to the Head Start program.

  Do oral health providers need to complete a Head Start oral health form for dental visits that have already occurred?

  No, oral health providers do not need to complete a form for dental visits that have occurred. The forms are intended for use at current dental visits.

  How can oral health providers enter information electronically in the Head Start oral health forms?

  The electronic form is designed for oral health providers to enter information into specific fields in the form. For best results, encourage providers to download the forms to their computer and open with Adobe Reader, which is available at no charge. Then they can enter information into the forms and save or print them.