SHA Benefits Fair x Floss Boss Appointment Request Form
Schedule with Floss Boss Mobile for a dental visit. Please note that all cancellations within 48 hours and no-shows will result in a $75 charge.
Have you been a patient with Floss Boss Mobile before? If you have, you do not need to fill out the insurance information another time.
*
Please Select
Yes
No
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Schedule your appointment with us!
We will be onsite at to provide dental cleanings on Tuesday 9/29
Please select time and date below.
*
Please provide us with your insurance group ID and subscriber ID in the following format [Group ID, Subscriber ID]. If you have seen us before, please indicate that in the box below.
*
Which of the following services are you interested in? (Please note: Some services may require referral to our office locations in Seattle. Whitening and Botox services are available but are not covered by Delta Dental.)
*
NEW PATIENT Exam/Cleaning
ROUTINE Exam/Cleaning
ROUTINE Exam/Cleaning WITH Whitening
Whitening (NO Cleaning)
Clear Aligner Therapy
Nightguard
Botox
Broken or Chipped Tooth
Problem with Crown or Bridge
Discomfort/Pain
Other
Submit
Should be Empty: