Dental - School fluoride varnish programme form | Kent Community Health NHS Foundation Trust

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Please read the whole form, complete your child’s details/answer all the medical questions and sign it at the bottom before it will be submitted.
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What is the a school fluoride varnish programme?

This programme aims to help prevent tooth decay in young children. Tooth decay is still very common in children and it can cause pain, stop children from eating, speaking, sleeping and also learning properly at school. The Department of Health (please see the 'delivering better oral health' document on the government website) recommends that fluoride varnish is applied at least twice a year to protect teeth.

What is fluoride varnish?

Fluoride varnish is a pleasant-tasting sticky protective coating which is easily painted on teeth. The golden coating releases fluoride which strengthens teeth, helps prevent tooth decay and can also stop decay in its early stages. The coating disappears by the next day.

What happens after the coating is applied?

The school will ensure that your child has nothing to eat or drink for 30 minutes after the coating is applied. Your child’s teeth may be a light yellow colour for the rest of the day - this is nothing to worry about as they will soon return to their normal colour. Please do not brush your child’s teeth on the evening they have the coating applied.

Additional Information

Please ensure your child has breakfast on the day of the varnish application.
The fluoride coating contains ethanol - a form of alcohol - and has been approved for medicinal use by the Islamic Shari’ah Council (your school has a copy of this approval) and by Rabbi Adler.
After a quick look, we will let you know if we notice any problems in your child’s mouth. However, this is not a dental check-up – your child still needs to have regular check-ups by a dentist outside school (see nhs.uk/service-search/find-a-dentist for a local dentist).
Please note the fluoride varnish is vegetarian and not vegan.

If your child cannot have the coating we will let you know why.

If you have any questions regarding the fluoride coating or the school visit please contact our Oral Health Promotion Team on 020 8496 7351/7352.

Dental Service - school fluoride varnish programme form

Borough(Required)
School (in Newham)(Required)
Newham only receive one application of fluoride in the academic year.
School (in Barking and Dagenhan)(Required)
School (in Hackney)(Required)
School (in Havering)(Required)
School (in Redbridge)(Required)
School (in Tower Hamlets)(Required)
School (in Waltham Forest)(Required)
Name of child(Required)
First Last
Class(Required)
Date of birth(Required)
Phone(Required)
Essential medical questions - does your child have?(Required)
- Asthma
- Any reaction to sticking plasters
- Any reactions to latex rubber
- Any allergies
- None of the above
If yes, please list any allergies below or we cannot apply the fluoride varnish(Required)
Permission(Required)
I give permission for my child to take part in the School Fluoride Varnish programme. A dental professional will have a quick look in my child’s mouth and apply fluoride varnish twice (once for Newham) this school year.
Consent(Required)
I confirm that I have read and understood all the information contained in this letter. By agreeing for my child to take part in this programme I understand that their information may be shared with the school to help support access to dental care.
Signature of parent or legal guardian(Required)
Parent or legal guardian name(Required)