This government document is issued by Department of Health for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:-o2sxg2obgu&q=https://www.health.pa.gov/topics/Documents/School%2520Health/School%2520Dental%2520Form.pdf&sa=U&ved=2ahUKEwivpILSr9D8AhVTiFwKHe2_D_E4FBAWegQIAhAB&usg=AOvVaw2-ivS9otoA8qg79qpMiS7R