December Dental Appointment Request Form
*Please complete a registration form for each household member interested in a dental exam.* Our staff are using this form to contact patients as appointments are available throughout the month. At the end of the month, if you have not been contacted to schedule an appointment, you can register again during the next open scheduling period of the following month.
Date of Birth:
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
If you do not see your dental insurance company listed as an option below, it is likely that we do not have a dentist currently available for exams that is enrolled with that insurance. This means that your insurance will not pay for services from our dentists. This list may change in the future. No one will be denied access for lack of insurance.
My insurance isn't listed
Careington Benefit Solutions
Dental Benefit Prov/UHC PPO
Dental Blue (same as Anthem BC/BS) 300,200,100
SunLife Financial (formerly DHA/Assurant)
Delta Medicare Advantage
UHC Dental Benefit Providers
United HealthCare Community Plan Medicaid/Medicare Plan
American Public Life Ins Co
Foreign Service Benefit Plan
Vernon Mem. Dental Cypress
This form is only available for submission on December 4th and December 5th, 2023.
Should be Empty: