Patient Eligibility Form
Please take a moment to complete the following information. Submission of this form does not guarantee eligibility, and additional information or supporting documentation may be required before eligibility can be determined.
Contact Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Applicant must be 18 years or older to be eligible.
Address (Must be a Pinellas County Resident)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
*
ER
Urgent Care
Health Department
Family/Friend
Clearwater Free Clinic
Homeless Empowerment Program (HEP)
Arc Tampa Bay
Find Help Florida
VA
Salvation Army
Villages of Hope
Gulf Coast Dental Outreach
Internet/Web Search
WVFR
211
Other
Household Income
Please provide the total number of individuals in your household.
*
A household member is defined as someone related by blood or marriage including unborn children.
Are you currently receiving any form(s) of income?
Please Select
Yes
No
Please select any types of income that apply.
Employment Income
Social Security
Retirement
Disability
Other
Does anyone else in your household currently receive income?
*
Please Select
Yes
No
Types of income received.
Work Pay
Social Security
Retirement
Disability
Other
Please upload supporting documentation for income verification.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance
Do you currently have any dental insurance?
*
Please Select
Yes
No
I don't know
Is anyone in your household currently enrolled in Medicaid?
*
Please Select
Yes
No
Are you currently in pain
*
Please Select
No, I am just looking to be established as a new patient.
Yes
On a scale of 1 to 10, please rate your pain.
*
1 being little to no pain, and 10 being extreme pain.
Please provide a brief description of your dental issue.
Submit
Should be Empty: