[Imported Form] Cass County Dental Clinic Teledentistry Enrollment

Cass County Dental Clinic Teledentistry 2025 Enrollment Form

Please fill out this form for each individual patient. Please do not continue if the form states you are not eligible for our services. If you have questions regarding eligibility, please give us a call- 816-322-7600. *Please note that you must submit all information at the same time. You will not be able to start enrollment and come back to it at a later time.
Please take a moment to review the PDF describing our Teledentistry Program.
Please select what you know to be true of the patient.

Medicaid is NOT considered private insurance.
Dynamic Dropdowns

Please select what you know to be true of the patient.

If you have already stated you are active with MO Medicaid, please select that choice again and move forward with the form.
Dynamic Dropdowns

Parent/Guardian Information:

The Responsible Party must be the patient’s parent or legal guardian and is the person who is the primary contact for the patient. Guardianship papers must be on file prior to the patient’s appointment. Please fax to 816-322-7606 or email to info@casscountydentalclinic.org.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Primary Phone*

Area CodePhone Number
Parent/Guardian Secondary Phone

Area CodePhone Number
Parent/Guardian Email*
Parent/Guardian Preferred Contact Method*

Phone callText messageEmail
Relationship to Patient*

Mother or FatherStep-parentFoster ParentLegal Guardian
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Emergency Contact Primary Phone*

Area CodePhone Number
Emergency Contact Secondary Phone

Area CodePhone Number

Cass County Dental Clinic Teledentistry 2025 Enrollment Form