Mobile Dental Registration Form

NEW Health's Mobile Dental Clinic

NEW Health is bringing high-quality dental care directly to your student's school with our Mobile Dental Clinic, to provide convenient, on-site dental care. This program makes it easier than ever for your student to receive their routine 6-month dental exam without leaving school—saving you time and minimizing time away from learning.
Services Offered Include:
- Dental exam by a licensed dentist
- Hygiene cleaning
- X-rays (as needed)
- Sealants (as needed)
- Fluoride treatment
- Oral health education
NEW Health’s Mobile Dental in Schools Program ensures a safe and comfortable environment for preventative care. If you'd like your student to participate, please complete and sign this form and treatment consents. Forms must be completed and submitted prior to the event date.

Need help or have questions?
- Call the school office or NEW Health at 509-935-6004 (press #2 for dental)
No Insurance? No Problem.
NEW Health offers a Sliding Discount Program and help enrolling in Medicaid or other plans via Patient Navigators at 509-935-6004 (option #5).

We’re proud to partner with our community schools to keep our students smiling—right where they learn and grow.

PARENT/GUARDIAN INFORMATION
Parent or Guardian Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Size
Estimated Household Income:

INSURANCE INFORMATION
Insurance Type
Insurance Plan Name
Policy or Medicaid Number (If you do not have your students Apple Health/Medicaid number available, please type "Contact Me" and continue. Our staff will reach out, if needed, for this information.)
Group Number
Subscriber Name
Subscriber Date of Birth
If you would like a call to discuss your dental insurance coverage, our Sliding Discount Program, or other questions please mark below. If Yes, you will receive a call after submission is completed.
Insurance Card Upload

Upload an image of the FRONT and BACK of your insurance card here.
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NEW Health's Mobile Dental Clinic