Dental Days

Dental Days Pre-Registration Form

Please complete the form below to register your interest in receiving free dental care through Dental Days. Submitting this registration form does not guarantee an appointment. After we receive your registration, our team will review your information and contact you approximately 2 weeks prior to the event regarding appointment availability. Dental Days is available to adult residents of Coconino County who are uninsured or underinsured, including individuals enrolled in AHCCCS.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
I don't have an email address
Home Address

Street Address

Street Address Line 2
CityState / ProvinceZIP Code Only
Requested Dental Services
Dental Pain or Discomfort
Are you currently experiencing any dental pain or discomfort?
Please tell us where you are experiencing pain or discomfort and anything you would like us to know.
Is there anything else you would like us to know about your dental needs or your difficulty accessing dental care?
Please understand that Dental Days has a limited scope of dental services. Our events provide dental cleanings, fillings, and extractions only. If a tooth needs to be extracted, Dental Days does not provide tooth replacement following the extraction. We do not provide: Dentures, Partial dentures, Flippers, Dental bridges, Crowns, or Root canals. If you need a tooth replacement or any of the services listed above, you will need to seek care from another dental provider.
Patient Acknowledgment – Dental Services Provided
Should be Empty:

Dental Days Pre-Registration Form

Dental Pain or Discomfort