Are you a Candidate for Medical Insurance Coverage?

1

Please select all that apply to your oral health* This field is required.Click multiple answers if applicable and click next

Dry Mouth

Decay resulting in tooth removal

Cavities

Root Canals

Dry and cracking lips

2

Please select the symptoms you relate with.Click multiple answers if applicable and click next

Fatigue

Joint Pain

Dry Eyes

Dry Skin/ Irritated Skin

Dry Mouth

3

Have you been diagnosed with Sjögren's Syndrome?* This field is required.Single choice answer

Yes

No

Unsure

4

Are you an Arkansas State employee?* This field is required.Examples: Arkansas Public School Teacher, Government Officials, Division of Emergency Management, Department of Health, etc.

Yes

No

5

Contact Information* This field is required.Please provide your contact information below. One of our patient advocates will be reaching out to you!

Please enter your Name

Please enter your phone number

Please enter your email address