DENTACOR SCHEDULING LINK

1

2

HAVE YOU BEEN SEEN BY DENTACOR IN THE PAST?* This field is required.

YESNO

3

WHAT IS YOUR NAME?* This field is required.

4

WHAT IS YOUR DATE OF BIRTH?* This field is required.

Date

5

DO YOU HAVE AN ACTIVE PHONE?* This field is required.

YESNO

6

WHAT IS YOUR PHONE NUMBER?

7

DO WE HAVE PERMISSION TO TEXT APPOINTMENT REMINDERS AND/OR APPTOINTMENT SPECIFIC COMMUNICATIONS?* This field is required.

YES

NO

8

CLICK "ALL" SERVICES YOU ARE INTERESTED IN RECEIVING:* This field is required.click ALL services that apply

EXAM

CLEANING

DENTURES

EXTRACTION ASSESSMENT

9

CLICK NEXT TO SCHEDULE APPOINTMENT LOCATION

10

SELECT PREFERRED APPT LOCATION:

SALT LAKE CITY LIBRARY

WEST JORDAN RESOURCE FAIR

11

SCHEDULE YOUR SALT LAKE LIBRARY APPOINTMENT:* This field is required.

12

SCHEDULE YOUR WEST JORDAN D.O.C. RESOURCE FAIR APPOINTMENT:* This field is required.

13

15

WE WOULD LOVE TO SAY THANK YOU, WHAT IS THE NAME OF WHO REFERRED YOU TO US?

16