Dentists on Wheels (DOW) Patient Application
Please fill out the following form for dental screening. Due to our limited availability, patients are chosen similar to a lottery system when reviewing applications. We will contact you if you are chosen!
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Email *
First and Last Name *
Address *
City *
Date of Birth *
Phone Number *
Sex *
Primary Language *
Need Translator? *
Are you a Veteran?
Clear selection
Do you have a disability?
Clear selection
Rate the pain in your mouth/teeth from 1-5 (1= no pain and 5 = extreme pain) *
Reason for visit or dental concerns *
Do you currently have any type of dental insurances? If YES, what kind? *
How did you hear about us? *
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