Eligibility Form
Answer a few questions to find out if your child is eligible for Little Lights Dentistry's free dental program.
Parent/Guardian Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Does your child have dental insurance?
*
Yes
No
Not sure
Does your child live or attend school in the Stuart or St. Lucie Area?
*
Yes
No
SCHOOL USE: Enter school referring
Reason for referral (parent or referral source)
Additional Comments or Questions
Parent has consented to this referral
*
Parent has consented to this referral
*
Yes
No
Parent has consented to this referral
*
Check Eligibility
Should be Empty: