Pennsylvania requires dental screenings at original school entry and in grades 3 and 7, and families may have their own dentist do it instead of the school dentist. H514.027 is the Department of Health's form for reporting that private exam: a tooth chart with decay surfaces, yes/no findings and treatment urgency. Schools in both the mandated dental program and the dental hygiene services program file it in the student's health record.
The parent or guardian can fill in the student demographics at the top: school, date, student's name, birth date, grade, section/room and address. The dentist or dental provider completes the tooth chart, exam row and findings, then signs, dates and prints their name and address.
The parent or guardian can complete these demographics. Enter the school the student attends, the date the form is completed in MM/DD/YYYY format, the student's last, first and middle name, date of birth in MM/DD/YYYY format, grade, section or room if applicable, and the full home address with borough or township, county, state and ZIP code.
Circle the number or letter of each existing tooth. The chart runs from tooth 1 to 16 across the upper arch and 17 to 32 across the lower arch, with primary teeth A to J (upper) and K to T (lower) printed alongside their permanent counterparts, oriented right and left. The circled chart gives the school a picture of the student's current dentition.
Below each tooth number or letter, write the codes for the surfaces where decay is present: buccal (B), distal (D), facial or labial (F), incisal (I), lingual (L), mesial (M) or occlusal (O). Separate exam rows sit under the upper and lower charts. Leave the box blank when a tooth has no decay.
Circle Yes for untreated decay when decay has not yet been treated, and No when all detected decay has been treated or there is none. Circle Yes for treated decay when decay has been treated, otherwise No. Circle Yes for sealants when they are present on any permanent molar, and No when there are none.
Assess the urgency of needed dental treatment from the screening findings and circle one option. None means no immediate treatment is necessary. Early means treatment can be scheduled at a routine future date. Urgent means immediate treatment is required because of pain, infection or risk of the condition worsening.
The dentist or dental provider dates and signs the form and prints their name and address, which the guidelines describe as certifying the accuracy of the screening and the completeness of the report. Then return the form to the parent or guardian and tell them to bring it to the student's school.
Download the current version from the source each time; forms change without notice.
Private Dentist Report of Dental Examination/Screening of a Pupil of School Age
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The Department of Health lists original school entry (kindergarten or first grade), grade 3 and grade 7 for the mandated dental program. Schools may request a modification of the grades from the Department. A family dentist's exam reported on H514.027 can replace the school screening if it falls within the accepted timeframe before school opens.
Circle each existing tooth on the chart, then use the exam row beneath each tooth number or letter to write the surface codes where decay is present: B (buccal), D (distal), F (facial or labial), I (incisal), L (lingual), M (mesial) or O (occlusal). Leave the exam row blank for teeth without decay.
The Department's guidelines define None as no immediate treatment needed, Early as treatment that can be scheduled at a routine future date, and Urgent as immediate treatment required because of pain, infection or risk of the condition worsening. Circle the one option that matches the screening findings.
The Department posts the Private Dentist Report only as a Word (.docx) file. Its guidelines say to open it in a compatible program such as Microsoft Word or Google Docs, then download and print it for completion. The School Dental Form, a separate PDF, is the school's own dental health record.