Name:

Social Security Number:

Date:

DEAR APPLICANT:

Your dental records are incomplete. The items checked below must be completed prior to dental clearance.
Dental clearance is independent of medical clearance.Even though you are not dentally cleared, PeaceCorps
will continue to process your application and you can still be invited to a specific country project. However,
all dental treatment must be completed and received by PeaceCorps 30 days prior to reporting to staging or
training. PeaceCorps reimburses up to $60.00of these costs. This letter MUST BE RETURNED with the
information requested.

01. The following radiographs (x-rays) were not received:

a. Full Mouth Seriesb. Panorex with 4 bitewing films

0 2. Dental Examination F~rm was not received/was incomplete.

;"
0 3. A letter from your dentist confirming completion of restoration
(fillings or crowns) of teeth #

0 4. A letter confirming extraction of third molars (wisdom teeth) #

These teeth are at risk of becoming symptomatic and there are inadequate facilities to treat dental-
problems in most developing countries.

0 5. A letter from your dentist confirming completion of treatment of periodontal disease.

0 6. A letter from your orthodontist confirming completion of 9Jlorthodontic treatment fuse of removable
retainer permitted).

0 7. Other

Do not send any information until all items checked above have been completed. When all items are
complete return your entire dental record (including x-rays) with the letters of confirmation from your dentist.
All letters MUST specifically list all treatment provided.

To inquire about your dental status call:

Toll-Free 1-800-424-8580Ext. 1500

To talk to the dentist about necessarydental treatment call:

Toll-Free 1-800-388-6603
Mondays & Wednesdays 8am -5pm ET

Fridays Sam -2pm ET

PC 1653