Healthy Smiles Ontario Parent Notification Form

Emergency and Essential Services Stream.

Your child needs dental care

Your child received the Healthy Smiles Ontario Parent Notification Form (Emergency and Essential Services Stream) because they received a dental screening recently and may need urgent dental care that should be treated by a dentist.

About Healthy Smiles Ontario

Healthy Smiles Ontario is a government funded dental program that provides free dental services for eligible children 17 years and younger.

If your household cannot afford dental care, fill out this form to apply to the Health Smiles Ontario Emergency and Essential Services Stream. It helps children get urgent dental care at no cost:

Children enrolled in this stream are covered for 6 months
Each child can enroll up to a maximum of 3 times in their lifetime

What to do with the form

This form helps you:

Confirm your child has received dental care, or
Apply for dental care through Healthy Smiles Ontario if needed.

You’re required to complete the form and return it to Peel Public Health using the prepaid envelope.

If you need help completing the form or have questions, call Peel Public Health at 905-799-7700, or toll-free 1-888-919-7800. We’re here to support you.

How to complete the form

Complete only one section of this form, either Section 1 or Section 2. Choose the section that applies to you.

Section 1: If your child is already enrolled in Healthy Smiles Ontario or your household can pay for dental treatment

Step 1: Check one of the following statements on the form

You can pay for the treatment or have dental benefits that cover the treatment, or
Your child is enrolled in Healthy Smiles Ontario.
- Provide HSO client ID number.
- Provide HSO dental card expiry date.

Step 2: Visit your child’s dentist and have Section 1 completed

Take your child to the dentist for treatment
Ask your dentist to complete and sign Section 1 on the form. This confirms that your child has visited a dentist for care

Step 3: Submit the completed form

Mail the completed, signed form to Peel Public Health using the prepaid envelope within 20 business days

Section 2: If your household cannot pay for dental treatment

Step 1: Complete Section 2A

Answer both questions:

Question 1, if you are unsure whether you could receive the Ontario Child Benefit, learn more.
Question 2, if you are unable to pay, select “Yes”

If you answered “Yes” to either question above proceed to Section 2B

Step 2: Complete Sections 2B and 2C

Fill out both sections fully
Ensure that your child’s information and your information are accurate and complete
Once finished, proceed to Section D

Step 3: Complete Section 2D (insurance information)

Households with dental insurance or the Canadian Dental Care Plan can still enroll in Healthy Smiles Ontario.

Answer the following questions on the form:

Does your child have insurance coverage that includes dental benefits? (Yes or No)
Are you able to afford to access other insurance first? (Yes or No). This question is asking if you can pay out of pocket costs after using private dental insurance. If No, select “No” and proceed to Section 2E

Step 4: Review and sign Section E

Carefully read the terms and conditions
Sign and complete Section 2E

Step 5: Submit the form