Dental Evaluation for Missionary Candidate

Renato G. Gerong
Brgy Tampoong
Sogod, Sogod
6606 Southern Leyte
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender
Kevin Carl Vasquez Reviso 0010080345211 26 Aug 2003 (19) Male

To the missionary candidate:

Please complete your dental examination early to allow plenty of time for all treatment, including active orthodontic treatment and wisdom teeth evaluation. Before your
dental appointment, answer the dental history questions below, and read and sign the authorization statement. Notify your stake or district president if you are unable to
schedule a dental exam. Missionaries and their families are responsible for the costs of any necessary dental work before and during your mission. Because you might
not have access to dental care during your mission, please be honest with yourself and your dentist about any issues (or potential issues) with your teeth or jaw, including
joint disorders or teeth grinding.

Dental History (to be filled out by missionary candidate)

Has all orthodontic treatment been completed? If yes, please bring an extra set of removable retainers with you to the
Yes No Not applicable
mission field.
Have your wisdom teeth been removed? (If not, discuss this with your dentist and have your wisdom teeth removed if
Yes No
there are any potential concerns. This care is not provided in the mission field.)
How often do you brush your teeth? How often do you floss your teeth?

Do you have any pain or bleeding in your mouth, teeth, gums, or jaw joints? If yes, explain.
Yes No

Authorization to Release Information

I authorize the examining dentist to release the information contained in this dental evaluation to my bishop or branch president and
the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by
dentists. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the
examining dentist from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of
Latter-day Saints or its agents.
Missionary candidate's signature Date

Witness's signature Date

To the examining dentist: Please be aware that this individual might serve in an area of the world (for 18–24 months) where there is little or no professional dental care
available, and any dental care will be at his or her own expense. Failure to provide the needed care now could result in significant health issues during the mission and
even the missionary’s early return home.

Dental Evaluation (to be filled out by dentist)

Has the prospective missionary had a complete oral examination with bitewing radiographs within the last six months?
Yes No
If the third molars have not been removed or are not erupted into proper alignment, has a panoramic or equivalent
Yes No Not applicable
image suitable for evaluation of the third molars been taken in the last 6–12 months?
Have all third molars that were likely to become problematic during the next two years been extracted? Any unerupted
Yes No Not applicable
molars must show proper alignment and space to erupt free of distal impingement or will not likely erupt.
Has all dental decay and gum infection been resolved?
Yes No
Has all active orthodontic treatment been completed? Please verify that bonded retainers are properly attached.
Yes No Not applicable
Is this individual practicing proper oral hygiene, including brushing and flossing?
Yes No
Given that this individual might not have access to professional dental care (including exams and cleanings) for 18–24
Yes No
months, do you believe that he or she will be free of dental problems for this period if proper oral hygiene is practiced?
Comments:

Dentist’s signature (Please complete all dental work before signing this form) Name of dentist Date completed or evaluated

Dentist's office address City State or province

Country Postal code District (if any)

Office phone (with area code) E-mail address (if available)

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