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School Form Request: Oral Health Assessment Form & School Entry Health Check-Up Form
To place your form request, please complete the online form below.
If you have any questions or need further assistance, please contact contact Nidia Croce at
Nidia.Croce@sdcounty.ca.gov
or (619) 692 - 8858.
Thank you.
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* Indicates required question
Name of School, District, or Agency
*
Your answer
Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Name: Contact Person / Attention To
*
Your answer
Email Address
*
Your answer
Phone Number
*
What is the contact person's phone number?
Your answer
Form(s) You Would Like to Request
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Please check all that apply:
Oral Health Assessment Form (Pink; Double Sided: English & Spanish)
School Entry Health Check-Up Form (Green; Double Sided: English & Spanish)
Required
Quantity: Oral Health Assessment Form
*
Your answer
Quantity: School Entry Health Check-Up Form
*
Your answer
Would you also like to request materials to help inform families about no-cost well child exams?
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Yes, please include the Child Health and Disability Prevention (CHDP) program information flyer with my order
No thank you
Required
If 'yes', how many CHDP information flyers would you like?
Your answer
Comments / Special Request(s)
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