Dental Form | CMCCAA

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931-896-1800

CMCCAA HEAD START DENTAL FORM

Email Address

Child's Name *

Date of Birth *

Oral Condition

Oral Condition NotesInclude notes on any missing, decayed, or filled teeth. Please indicate any restorations completed in the Restoration field below.

Treatment Provided:

Treatment Needed:

ExamX-rayProphylaxis (cleaning)Restoration (indicate below)SealantsFluorideFluoride Supplement

No treatment at this timeAll treatment completedFillingsRoutine preventive servicesReferral to PedodontistOther (indicate below)

List all restorations performed.

Other:

Date of Next Appointment *

Comments:

Date of Service *

Dr. Name (print) *

Dr. Signature *

Clinic *

Address *

Phone *

Fax

For questions or additional information:
CMCCAA Head Start
150 Lafayette Rd, Clarksville, TN 37042
📞 (931) 896-1800
📠 (931) 542-4671

Please contact the agency directly for dental reimbursement guidelines.

Save & Finish Later

We're a Community Action Agency serving Clarksville-Montgomery County, created back in 1964 to help fight poverty. We're here to support local families with everyday services and programs that make life a little easier.

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Phone: 931-896-1800
Address: 150 Lafayette Road Clarksville, TN 37042

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