Veterans Dental Day Patient Registration

Veterans Dental Day Patient Registration

Please fill in the form below
Name*

First NameLast Name
E-mail
Gender*
Are you pregnant?*

YesNo
How many weeks pregnant are you?*
Date of Birth*

MonthDayYear
Date
Are you taking a blood thinner or anticoagulant such as, but not limited to, Warfarin (Coumadin), Rivaroxaban (Xarelto), Heparin, Apixaban (Eliquis), or Clopidogrel (Plavix)?*

YesNo
What blood thinner or anticoagulant are you taking?*
Contact Number:*

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Branch of Military*
Please Upload a Picture of Your Military ID or DD214

Browse Files

Cancelof
Please Upload a Picture of Your Photo Identification

Browse Files

Cancelof

What is your main dental concern to?*
Taking any medications, currently?*

YesNo
Please list medications you take*
Do you give Healing Hands Health permission to use your photograph for recognition, advertising, and promotion of future events?*

YesNo
Would you be willing to have Healing Hands Health interview you for a story and take your picture?*

YesNo
The information I have provided on this form is true and accurate to the best of my knowledge. Signature:*

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