Adopt-A-Vet

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Adopt-A-Vet

Patient Criteria Form

Thank you for considering "Adopting-A-Vet"! Please feel free to share any information you think will help us best suit your criteria...

Practice Name *

Who should the patient ask to speak with when calling to schedule? *

What is the best office contact phone#? *

What is the best office email to send pt information? *

How many Vets would like to help? *

One Veteran

Two Veterans

Three Veterans

Other:

We are a *

General Dentistry Practice

Endodontic Practice

Oral Surgery Practice

Other:

We will treat

Somewhat comprehensively if Placer Veterans Stand Down will help cover lab costs

Limited treatment - fillings and cleaning only

Oral Surgery only

Endo only

Other:

Please give us any other information that may help us match you with the right veteran.

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