MHP Dental Van 4/10/2021 - Mountlake Terrace
Dental Procedures Include - Extractions, Fillings +
***Please check your eligibility below***
- ADULT (18+) Patients only
- uninsured, not holding any dental insurance
- household income is BELOW 200% of the Federal Poverty Level. Please check the image below.

Unfortunately due to limited slots, submitting this form DOES NOT guarantee an appointment. We will do our best to meet everyone's needs, and appreciate your cooperation. For questions, please email mhpseattle@gmail.com or call/text 425- 326-0463
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Name of Patient (First, Last) *
Phone Number *
What is your concern? (What hurts?)
Preferred Appointment Time (select a time period to get an appointment, first come, first serve) Apprx. 45 min *
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