Dental Appointment Request Form First Name* Last Name* Email* Cell Phone* Tel. Home Address* City* ZIP Code* Date of Birth* Gender* Male Female Ethnicity* Hispanic Non-Hispanic Race*WhiteBlackAsian/PIAm Indian/ Alaskan Native2 or more racesOther Are you a new patient?* Yes No Appointment Type* Cleaning Extractions Fillings Do you have health insurance?* Yes No Reason for Visit* Referral Source* ORMC Advent Health Healthlink Christian Sharing Patient in the practice Word of mouth Bueno Pharmacy Other Remarks Urgency? This appointment is urgent. Add me to the waiting list. If available, I can come within 24 hours notice. Yes No Food Security Questionnaire (Optional) Are you currently receiving any food assistance, such as SNAP, WIC, food banks, or free meal programs? Yes No In the past 12 months, have you or your household been concerned about running out of food before having the money to buy more? Often true Sometimes true Label In the past 12 months, has your household run out of food without enough money to buy more? Often true Sometimes true Never true How often do you skip meals due to financial difficulties? Frequently Occasionally Rarely Never Would you like to be notified if free food assistance opportunities become available? Yes No -.* By submitting the request, I affirm that I don't have any type of insurance and my last 30 days gross household income is less than 300% below the federal poverty line. Submit Error occured. Please confirm your data and submit again:
