How to Fill Out and Submit the Head Start Dental Form

The Head Start dental form is a one-page document you start and a dentist finishes: you fill in your child’s name and contact information at the top, bring it to a dental appointment, and the dentist records the exam findings and signs the bottom. You then return the completed form to your Head Start program’s health coordinator. Federal rules give programs 90 calendar days from your child’s first day of attendance to obtain this professional determination of oral health status.1eCFR. 45 CFR 1302.42 – Child Health Status and Care

Where To Get the Form

Your local Head Start program should give you the form, either in your enrollment packet or as a download from the program’s website. If you didn’t get one, ask your program office directly. HeadStart.gov’s application guidance points families to their local grantee for all required paperwork.2HeadStart.gov. How to Apply

Programs aren’t required to use one standard form. Each program can set up its own system for documenting oral health services, so the layout you receive may look different from another family’s.3HeadStart.gov. Head Start Oral Health Forms HeadStart.gov does publish a standard children’s version as a PDF, and many programs use it or something close. If you want to get started before your program hands you paperwork, download that version, but confirm with your health coordinator that they accept it before the appointment.

What You Fill Out Before the Appointment

The patient information block at the top is the only part that’s on you. On the standard version it asks for:

  • Child’s full legal name, as it appears on program enrollment records
  • Date of birth
  • Parent or guardian name
  • Phone number
  • Address, city, state, and zip code

Do this at home. Arriving with the top already filled in keeps the dental visit focused on the exam, and it prevents small mismatches between the form and your program’s records, which can hold up processing. Check the child’s name and date of birth against enrollment paperwork before you go.

What the Dentist Fills Out at the Visit

Everything below the patient information section is the dentist’s responsibility. Knowing what each section captures makes it easier to follow along and ask questions before you leave.

Current Oral Health Status

The dentist marks whether the practice qualifies as your child’s dental home, meaning an ongoing source of preventive and primary oral health care that includes diagnostic testing, examination, and treatment.4HeadStart.gov. Dental Assessment and Treatment Three yes-or-no questions follow: does the child have untreated decay, have any teeth been treated for decay in the past (fillings, crowns, or extractions), and is additional treatment needed. If more treatment is needed, the dentist marks it as urgent or not urgent.

Diagnostic and Preventive Services

This section records what was actually done at the visit. The dentist checks yes or no for the exam, x-rays, a risk assessment for tooth decay, a cleaning, fluoride varnish, and dental sealants. X-rays are done when the child’s history or clinical findings call for them, not automatically.

Fluoride varnish comes up often for young children. Head Start programs are required to facilitate topical fluoride treatments, and where the water supply lacks adequate fluoride or a child has moderate to severe decay, the program must also facilitate fluoride supplements and further treatment as the dental professional recommends.1eCFR. 45 CFR 1302.42 – Child Health Status and Care

Restorative, Emergency, and Specialty Care

If your child needed restorative work, the dentist checks the box for fillings, crowns, extractions, or emergency care. An “Other” line handles anything outside those categories. A separate field records whether the child has been referred to a specialist and the type of specialist.

Future Oral Health Care Services

This is the section most parents look at first. The dentist notes whether all treatment is complete, sets the next recall date for a routine checkup, and lists how many additional appointments are needed if treatment is still ongoing. If the next appointment is already booked, the date and time go here.

Provider Signature and Contact Information

At the bottom the dentist provides a printed name, phone and fax numbers, practice name and address, signature, and date of service. Head Start health staff use this information to verify findings and coordinate follow-up. Before you leave the office, glance at this block and make sure every line is filled. A form returned without a provider signature or contact details will come back to you for correction.

Deadlines You’re Working Against

Two clocks start on your child’s first day of attendance, not the enrollment date:

If the program itself operates for 90 days or fewer, the oral health determination has to happen within 30 days of the child’s first attendance.1eCFR. 45 CFR 1302.42 – Child Health Status and Care

Don’t wait. Pediatric dental appointments can be weeks out depending on where you live, and if the dentist finds anything that needs treatment, you’ll want time for follow-up visits inside the same deadline window.

How To Submit the Completed Form

Once the dentist signs, return the form to your Head Start program’s health coordinator. Most programs accept it in person at drop-off or pickup, by mail to the central office, or as a scanned upload through a parent portal. Ask which method your program prefers. Some programs process scanned copies faster because they track submissions electronically. Keep a copy for yourself no matter how you submit.

The health coordinator reviews the form to confirm every section is filled in. Blank fields or a missing provider signature will come back to you. If the dentist flagged treatment as needed, program staff will follow up to make sure appointments get scheduled. Under federal performance standards, the program has to help you arrange care and, with your consent, can facilitate oral health services directly.1eCFR. 45 CFR 1302.42 – Child Health Status and Care

If the Dentist Finds Problems

When the form shows untreated decay or a specialist referral, the “Future Oral Health Care Services” section becomes your plan. It tells you how many appointments are likely and when the next one is scheduled. Head Start staff are required to facilitate and monitor any necessary treatment and follow-up until care is complete.1eCFR. 45 CFR 1302.42 – Child Health Status and Care

After treatment finishes, ask the dentist to update the form or write a short note confirming everything is done, and bring that back to your health coordinator so your child’s record can be closed out. The program will keep helping you stay on schedule with routine checkups, typically every six months, for as long as your child is enrolled.

Insurance and Cost

Most Head Start families qualify for Medicaid or the Children’s Health Insurance Program, both of which cover pediatric dental services. Under Medicaid’s EPSDT benefit, states must provide dental services at intervals meeting reasonable standards of dental practice, and any condition identified in a screening must be treated.6Medicaid.gov. Dental Care For a covered child, the exam and preventive services on the form should carry no out-of-pocket cost.

If your child doesn’t have coverage when they start Head Start, tell the health coordinator. Within 30 days of the first attendance day, program staff are required to help families access a source of care and health insurance as quickly as possible.1eCFR. 45 CFR 1302.42 – Child Health Status and Care Connecting families with dental providers and insurance enrollment is part of the coordinator’s job, and where nothing else is available, the program can facilitate services directly.