NY Capital Region Community Dental Event | Saturday, October 21 (9-4)

Welcome to the registration for the free dental screening event! Scheduling an appointment at this event will allow us to provide you with an exam of your mouth, limited dental services and connect you to dental care.

Please note, if you are you experiencing any Covid or Flu symptoms, we encourage you to stay at home and not attend the event.

To register for an appointment request, you must be 18 years of age or older. If you are under the age of 18 years, please contact a parent or guardian to complete this form.
YesNo
Parent or Legal Guardian Info
Contact Info
Relationship to patient(s) ?
Parent or Guardian Name

First NameLast Name
Name

First NameLast Name
Primary Email
example@example.com
Secondary Email
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please select screening hour you prefer: (your appointment time will be confirmed prior to event*
What is the best phone number to contact you? *
YesNo
Patient Information
Patient Full Name*

First NameLast Name
Patient D.O.B.*

MonthDayYear
Date
Patient Gender*
Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
NoYes
Please provide Patient drug allergies
NoYes
Please list any current medications for Patient
Dental History
Is patient currently experiencing any pain?
Tooth AcheCavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingSensitive TeethJaw Joint PainOther
How often does Patient brush their teeth daily ?*
When was the Patient's last visit to a dental office ?
FINAL BREAK POINT
Insurance Info
Do you have dental insurance ?*
Choose your insurance provider
Please enter your insurance provider
Other Insurance Provider Name
Confirm today's date*

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Date
Signature*

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Should be Empty:

Parent or Legal Guardian Info

Contact Info

Patient Information

Dental History

FINAL BREAK POINT

Insurance Info