Student's Name:

Williamsville Central Schools

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Grade:

A comprehensive dental examination was performed on the above named student.

Dental work completed: _

Under treatment:

No further treatment necessary: _

Date: _

Dentist's address and phone: _

Dentist's printed name and signature: _

New York State Education Department requires proof of a comprehensive dental exam upon entranceto the school district. The school district strongly recommends a full dental examination uponentrance or in grades K, 2, 4, 7, 10.

It is required that this form be completed and submitted to the school nurse within 30 days of theentrance to school.

If you need assistance in locating dental services, there is a list on the reverse side of this formthat may be helpful to you. Dental services offered by these providers are either free or reduced,and accept most insurances, including Medicaid. Please address your specific concerns with theproviders prior to your appointment. If you would like additional information or assistance in finding adentist, the contact information for The Eighth Dental Society is also listed.

Thank you for your cooperation.

105 Casey Rd, P.O. Box 5000, East Amherst, NY 14051-5000 Phone: (716)626-8007, Fax:(716) 626-8090

www.williamsvillek12.orq

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COMMUNITY DENTAL CLINICS

WESTERN NEW YORK, ERIE COUNTY

University Pediatric Dentistry (Six locations)Call for individual clinic hours, insurance informationand appointments.

\. Women's and Children's Hospital of Buffalo239 Brant Street, Buffalo, NY 14222(716) 878-7758 (Closed for lunch 12-1 :00 PM)

2. University Pediatric Dentistry1660 Hopkins Road, Getzville, NY 14068(716) 688-7712

3. Toy Town / University Dentistry100 Riley Street, East Aurora, NY(716) 855-8880

4. UB School of Dental Medicine

Pediatric Dentistry Department107 Squire Hall, Buffalo, NY 14214(716) 829-2723

5. Pediatric Dental CenterMercy Hospital Marian Center515 Abbott Road, Buffalo, NY 14220(716) 828-3575

6. University Pediatric Dentistry521 Buffalo Street, Niagara Falls, NY(716) 282-4557

* Adult Services - UB School of Dental Medicine

offers 10 community locations. Call for info at (716) 829-2821

Erie County Department of Health Clinics(Call for clinic days and hours, all accept Medicaid)

1. Jesse Nash608 William Street, Buffalo, NY 14206Phone: 858-2198, M-F: 8:30 AM - 4:30 PM(closed 12 - I :00 PM)

2. Community Health Center of Buffalo462 Grider Street, Buffalo, NY 14215Phone: (716) 898-4449

3. Judge Mattina Community Dental Clinic& Health Center300 Niagara Street, Buffalo NY 14201Phone: (716) 859-4220

Women and Children's Hospital of Buffalo239 Bryant Street (Bryant and Elmwood Ave)Bulfalo, NY 14222, Phone: (716) 878-7758M-F: 8:30 AM - 3:30 PM; Saturday for established patients for cleanings

(8:00 AM - 11:00 AM) Accepts Medicaid and most insurances(Except CSEA, Family Health Plus, call first)

Deaconess Dental Clinic1001 Humboldt ParkwayBuffalo NY 14208 (Off Kensington, area of Science Museum, clinic acrossstreet from parking lot on Kinglsy). Phone: (716) 887-8079 M-F: 8:00 AM­4:00 PM. Specializes in patients with special needs. Accepts Medicaid only.

Buffalo General Oral Surgery Clinic100 High Street, B4, Buffalo, NY 14203Phone: (716) 859-7300

Erie Community College (ECC), North CampusDental Hygiene Clinic6205 Main Street (S Building off Wehrle Drive)Williamsville, NY 14221, Phone: (716) 851-1336

Sept - Dee: M-Th: 9:00 AM, 1:30 PM, 5:30 PMJan - June: M-F: 9:00 AM, I :30 PM, 5:30 PMClinics are Free. Offers exams, cleanings/polish, sealants, fluoridetreatment, x-rays, referrals (no fillings)

Baker Victory Dental Clinic790 Ridge Road, Lackawanna, NY 14218 (From mainline Thruway, RidgeRoad exit). Phone: (716) 828-9334. M-F: 8:00 AM - 6:00 PM, Sat: 8:00 AM­1:00 PM. (Accepts Medicaid, most insurances, except Fidelis, GHI, others)

Kalieda Health Family Dental Clinic @ Sheehan Health Network425 Michigan Avenue, Buffalo, NY 14203, Phone: 848-2340, M-F: 8:00 AM ­

4:00 PM (Accepts Medicaid, private insurance, Medicare, charity care)

Kalieda Health Millard Fillmore Hospital Dental Clinic3 Gates Circle, Buffalo NY 14209Phone: (716) 887-4654

NIAGARA COUNTY

Founders Health Clinic6507 Wheeler Road, Lockport, NY 14094Phone: (716)433-4070

Mizer Clinic501 10th Street, Niagara Falls, NY 14301Phone: (716) 285-2993

4.

5.

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Matt Gajewski Health Center1500 Boradway Street, Buffalo NY 14212Phone: (716) 891-2005

Northwest Buffalo Community Health Center155 Lawn Avenue, Buffalo NY 14207Phone: (716) 875-2904

For more dentists (pediatric or adult), who accept Medicaid, call the Eighth Dental Society of Western New York, call(716) 858-8666For a more complete listing of local area dentists (pediatric or adult), you may contact the Eighth Dental Society ofWestern New York at (716) 995-6300 or website at www.8thdistrictdental.org