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Waushara County Shar-A-Smile


WausharaCounty is offering a preventative dental sealant program for ALL students in 2nd,5th & 7th grades.  This program is funded by the Wisconsin Seal-A-Smile, a collaborative program of Children’s Health Alliance of  Wisconsin and the Wisconsin Division of Public Health Oral Health Program.  A Registered Dental Hygienist will come to the school to provide the sealant program at NO CHARGE TO YOU.  The program includes: assessment to determine if sealants can be done, sealants as needed, a fluoride treatment and tooth brushing instructions with a new tooth brush.  A follow-up letter will be sent home to describe what was completed and what is recommended for future needs.  All procedures will follow recommendations from the American Dental Association and Centers for Disease Control and Prevention’s recommendations for school-based dental sealant programs.  This permission is effective for two years in order to replace any lost sealants when checked after one year or to have sealants applied on teeth that were not sealed this year.




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Please answer the following questions about your child: (Circle One)
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I authorize the Waushara County Shar-A-Smile program to see my child for the dental sealant program. This permission is effective for two years in order to replace any lost sealants when checked after one year or to have sealants applied on teeth that were not sealed this year.
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Information on the Waushara County Privacy Notice which describes how medical information about your child may be used and disclosed can be found on the Waushara County Health Department Website at http://www. co.waushara.wi.us **The treatment which your child will receive in this program is not meant to be an alternative to regular dental care. It is still strongly recommended that you seek out a dental home (family dentist) for routine dental care including follow-up care which may be recommended after your child has completed this school based oral health program.




Waushara County
209 S. Saint Marie St.   Wautoma, WI 54982      
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