Illinois’s Proof of School Dental Examination form is a two-part document you download from the Illinois Department of Public Health, fill out at the top with your child’s identifying information, and bring to a licensed dentist, who completes and signs the clinical section. It must be submitted to your school by May 15 of the school year for every child in kindergarten, second, sixth, or ninth grade. A receipt or printout from the dental office will not substitute for the official IDPH form.1Illinois State Board of Education. School Dental Examinations
Who Needs the Form and By When
The requirement applies to every child in kindergarten and in the second, sixth, and ninth grades at any public, private, or parochial school in Illinois.2FindLaw. Illinois Statutes Chapter 105 Schools 5/27-8.1 The exam itself must have happened within 18 months before May 15 of the current school year. A routine cleaning from the previous fall usually counts, so in many cases you only need the dentist to transfer the findings onto the official form.3Illinois Department of Public Health. Proof of School Dental Examination Form
Miss the May 15 deadline for a second, sixth, or ninth grader, and the school can hold your child’s report card. The hold lifts when you present proof of a completed exam or proof that an exam is scheduled within 60 days after May 15.4Illinois General Assembly. Illinois Code 105 ILCS 5/27-8.1 – Health Examinations and Immunizations Treat that 60-day window as a safety net, not an extension to plan around.
Where to Download the Form
Get the form from the IDPH oral health page at dph.illinois.gov. Both English and Spanish versions are posted there.1Illinois State Board of Education. School Dental Examinations School offices and school nurses usually keep paper copies as well. Download the current version each year. Older versions may be missing fields the state now requires, and a school can reject an outdated form on that basis.
What You Fill In as the Parent
The top of the form belongs to you. Enter your child’s full name, date of birth, and gender, along with your home address and phone number. Match the name to what the school has on file so office staff can tie the form to your child’s record without having to call. That is the entire parent section. Leave everything below the patient information line blank for the dentist.
What the Dentist Completes
Bring the partially completed form to your child’s appointment. The dentist fills in the clinical portion, which asks for more than a simple pass or fail:3Illinois Department of Public Health. Proof of School Dental Examination Form
- Date of the most recent examination, which must fall within 18 months before May 15 of the school year.
- Services provided at the visit, such as cleaning, sealant, fluoride treatment, silver diamine fluoride, or restoration of teeth due to cavities.
- Oral health status: whether sealants are present on permanent molars, whether the child has any history of cavities or fillings, whether untreated cavities exist, and whether the child needs urgent treatment, meaning abscess, nerve exposure, pain, infection, or swelling.
- Treatment needs, including whether follow-up is restorative or preventive, the appointment date, and any referral to a pediatric dentist.
- Dentist information: office address and phone, signature, license number, and date signed.
The signature and license number give the form its legal weight. A form missing either will come back to you. If the dentist flags untreated cavities or urgent treatment needs, school health staff will reach out to confirm your child receives the recommended care.
How to Submit It
Hand the completed form to the main office or school nurse. Many districts now accept a scanned upload through the school’s online student portal, but ask first. Some schools still require the paper original. Keep a photocopy either way. Forms do get misplaced in school offices, and a backup saves you from starting over.
School health staff review each form to confirm the required fields, signature, and license number are present and that the exam date falls within the 18-month window. If something is off, the school will contact you, usually by email or a note home, so you can fix it before the end of the year. Once the form passes review, the school updates your child’s compliance status in the state reporting system.
Waivers and Religious Exemption
If an exam is genuinely out of reach, Illinois offers a separate Dental Examination Waiver form. It is not a general opt-out. You qualify in these situations:5Legal Information Institute. Illinois Administrative Code Title 77, Part 665, Subpart F, Appendix E – Dental Examination Waiver Form
- Your child is enrolled in the free or reduced-price lunch program and has no private or public dental insurance.
- Your child is on the lunch program but does not qualify for Medicaid or All Kids.
- Your child has Medicaid or All Kids, but no dentist or clinic in your community that accepts it can see your child.
- Your child has no dental insurance and no low-cost clinic in your area will see them.
Illinois also allows an exemption on religious grounds. The parent submits a written statement explaining the specific religious basis for the objection, following the procedures in the Department of Public Health’s administrative rules.1Illinois State Board of Education. School Dental Examinations
The waiver form itself has to be filed by May 15. It is on the same IDPH webpage as the exam form, in English and Spanish. A completed waiver keeps your child’s file compliant and prevents a report card hold.
Low-Cost Ways to Get the Exam Done
Without insurance, a pediatric dental exam and cleaning can run $75 to $400. Before falling back on the waiver, check these routes.
Children on All Kids or Medicaid can get the exam at no out-of-pocket cost. Some schools participate in the All Kids School-Based Dental Program, where a licensed provider comes to the school, examines students, and completes the IDPH form on site, so parents do not need to schedule a separate appointment.6Illinois Department of Healthcare and Family Services. All Kids School-Based Dental Program Requirements Ask your school nurse whether your district offers it.
Federally Qualified Health Centers also provide dental services on a sliding fee scale based on family income and size. Families at or below 100 percent of the federal poverty guidelines pay only a small flat fee, and those between 100 and 200 percent receive partial discounts. No patient can be turned away for inability to pay.7Health Resources and Services Administration. Chapter 9 – Sliding Fee Discount Program Find a nearby center through findahealthcenter.hrsa.gov.
How the Form Is Handled Once It’s On File
Once submitted, the form becomes part of your child’s education record and is protected under the Family Educational Rights and Privacy Act (FERPA).8Protecting Student Privacy. Joint Guidance on the Application of FERPA and HIPAA to Student Health Records The school cannot share the dental findings with outside parties who lack a legitimate educational interest without your written consent. You can review the form in your child’s file and ask for corrections if something was recorded inaccurately. When the student turns 18, FERPA rights transfer from you to them.