Dental Care Request Form

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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Dental Care request form

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