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 new patient?*YesNo Appointment Type* Cleaning Extractions Fillings Do you presently 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 -. 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 200% below the federal poverty line. Urgency? This appointment is urgent. Add me to the waiting list. If available, I can come within 24 hours notice. Yes No Submit Error occured. Please confirm your data and submit again:
