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Dental Care request form
This form is not used to schedule extractions.
Name
This field is for validation purposes and should be left unchanged.
Full name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Address
(Required)
Street address
City
State
Zip code
Phone
(Required)
Have you received dental care, other than extractions, at Catholic Charities in the past 3 years?
(Required)
Yes
No
What dental care are you seeking?
(Required)
Are you currently experiencing dental problems or pain?
(Required)
Yes
No
Please list any health problems:
(Required)
Do you have a current dentist?
(Required)
Yes
No
How long has it been since your last cleaning?
(Required)
Are you employed?
(Required)
Yes
No
If yes, where? For how long?
(Required)
Do you have dental insurance or other means to pay for dental care?
(Required)
Yes
No
What is your monthly take-home income from all sources, including Social Security, disability, child support, public assistance, etc.?
(Required)
How did you hear about our clinic?
(Required)
Disclaimer
(Required)
Submitting this dental care request form to Catholic Charities does not guarantee your selection into the dental program. Each form will be reviewed upon receipt, and patients will be selected based on patient need, appointment availability, and resource availability.
You will only be notified if we are able to provide care for you. If you have not been contacted within 2 months, you may submit another Dental Care Request Form. Please understand that there may be times when we do not actively accept new patients.
I understand that Dental Care at Catholic Charities does not keep a waiting list and that submission of this form does not guarantee treatment. I assure that all of the information provided here is accurate and true.
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