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  • Section 1 (Bronze)

  • 1. Does your practice display the From the First Tooth (FTFT) “Baby Teeth Matter” poster in waiting room/s?
  • 2. Does your practice provide the From the First Tooth Year by Year trifold and Fluoride Varnish rack card to patients?
  • 3. Who is your designate FTFT champion?
  • What is his or her email?
  • 4. Did you submit baseline and bi-annual data to the Form the First Tooth website? If not, please upload your data directly after completing this form!
  • Section 2 (Silver)

    User needs to successfully complete section 1 to proceed to section 2.
  • 5. Has your practice been trained in the past three years to provide fluoride varnish either through an in person training by FTFT or the virtual training on our website?
  • 6. Are at least half of the practice staff trained who are responsible for the oral health assessments and fluoride varnish?
  • 7. Does your practice have a system in place to ensure delivery to all children in the practice receiving fluoride varnish (an established workflow)?
  • 8. Did you submit baseline, bi-annual, and annual data?

    If not, please upload your data directly after completing this form!
  • a. Is your data increasing toward annual metric goal?
  • Section 3 (Gold)

    User needs tosuccessfully complete section 1 and 2 to proceed to section 3.
  • 9. Did your practice reach 60% of children who receive a fluoride varnish in each of the target age groups during the last calendar year?
  • 10. Does your practice have oral health metrics built into the EHR or documentation system to guide quality improvement and measure performance?
  • 11. Does your practice document the dental home within the EHR?
  • 12. Does your practice have a standard clinical workflow in place?
    a. If yes, please email your workflow to
  • 13. Is your practice willing to be involved in one mentor call with another pediatric practice in coordination with FTFT (virtually)?
  • a. If yes, please indicate a primary contact to coordinate this call (name, role and email address):