Dentists on Wheels (DOW) Patient Application

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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!

Email *

First and Last Name *

Address *

City *

Date of Birth *

YYYY

Phone Number *

Sex *

Female

Male

Other:

Primary Language *

Need Translator? *

Yes

Maybe

Are you a Veteran?

Yes

Clear selection

Do you have a disability?

Yes

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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