Medicaid Waiting List Submission
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
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