Free Dental Care Weekend RSVP
December 12–13, 2025 | 8am - 5pm
Location: Greeley Dental Care, 5214 W 20th Street, Greeley
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Preferred Contact Method
*
Text
Call
Email
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How many people are you bringing (including yourself)?
*
Please include their names and birthdays
Please enter any questions on your mind or concerns that you do not see listed on the form
Are you planning to come Friday, Saturday, or either day?
*
Friday, December 12
Saturday, December 13
Either Day Works
Approximate Arrival Time:
*
Please Select
Morning (8–11)
Midday (11–2)
Afternoon (2–5)
Treatment Needs (Select all that apply)
*
Cleaning
Filling
Tooth Extraction
Other/Unsure
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Please check each box to confirm you understand:
*
I understand that services are provided free of charge by licensed volunteer dentists and hygienists.
I understand that treatment availability depends on capacity each day and that walk-ins will be seen on a first-come, first-served basis.
I understand that no sedation or advanced restorative procedures (such as crowns, implants, or dentures) will be performed.
I understand that if I experience complications or need additional treatment after the event, I will need to follow up with my regular dentist or healthcare provider.
Comments & Questions
Please enter any questions on your mind or concerns that you do not see listed on the form
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