Patient Interest Form
Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Are you sober from any drugs or alcohol?
*
Yes
No
Are you HIV positive?
*
Yes
No
What is your sober date?
*
Do you smoke or use nicotine?
*
Yes
No
Do you have a sponsor? If so, are you willing to let me talk to him/her?
*
Yes
No
Are you on Suboxone?
*
Yes
No
What was your Drug of choice?
*
Do you have Hep C or HIV?
*
Yes
No
How many teeth do you currently have (top and bottom)?
*
Do you have a denture?
*
Yes
No
How long have you been missing teeth?
*
How's your diet today?
*
Are you able to chew most foods?
*
Yes
No
Height
*
Weight
*
Are you on probation or parole?
*
Yes
No
If you answered yes to the previous question, when does that end?
Date
Are you diabetic or have you ever been treated with chemotherapy?
*
Yes
No
Are you in pain?
*
Yes
No
What Major City do you Reside near?
What State do you Reside in?
What County do you Reside in?
What treatment center did you attend?
From which jail were you released from?
Please leave your Sponsor’s name and contact info. Please do not register twice, if you have previously. We have you on the list and will contact you soon. Thank you for your patience.
*
Submit
Should be Empty: