Medicaid Waiting List Submission
Please note if you are Carlisle County resident, you may come to the office during normal business hours to fill out paperwork and have an appointment scheduled for a future date. You will need to bring your insurance card and ID with a Carlisle County address.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
*
-
Month
-
Day
Year
Date
What company provides your Medicaid coverage?
*
Aetna Better Health
Humana Healthy Horizons
Passport by Molina
Wellcare
United Healthcare
Which of these best describes you? (Please note if you are concerned about non painful cavities, please select a "cleaning" option)
*
I need a cleaning and exam, I have seen a dentist in the last 2 years, I have never been told a need a deep cleaning
I need a cleaning and exam, I have not been to the dentist in 5-10 years or I have been told I need a deep cleaning before
I need dentures
I have a specific tooth bothering me that I would like to address
Other
If you selected "other" to the question above, please provide a brief description of your dental needs.
What is your preferred time of day/ day of the week for appointments?
*
Monday Morning (8-11)
Monday Afternoon (1-3)
Tuesday Morning (8-11)
Tuesday Afternoon (1-3)
Wednesday Morning (8-11)
Wednesday Afternoon (1-3)
Thursday Morning (8-11)
Thursday Afternoon (1-3)
Submit
Should be Empty: