Patient Application for HealthLink Dental Clinic

  • APPLICATION TO BECOME A PATIENT

  • 1- Do you meet the patient requirements?

    To be a HealthLink Patient:

    • You must be at least 18 years old
    • You must live in either Bucks County or Montgomery County
    • You must not have dental insurance
    • You or your spouse/domestic partner must be employed (full-time,part-time, or seasonally) and
    • The total income of your household must be less than the limits listed below (See Chart)     

  • If you do not meet HealthLink's requirements, there are other resources that are available to you.  CLICK HERE to view other places to receive free or low-cost dental care.

  • 2- Complete the online application AND send us these documents.

    • Most recent 2 months of paystubs;
    • Completed federal tax return (Form 1040) & schedules, if applicable, for the current year;
    • Proof of residency, such as utility bill or signed rental leease; and
    • Photo ID (drivers license, passport, or work ID)

  • GENERAL INFORMATION

  • Preferred Pronoun
  • Date of Birth *
     - -
  •  -
  •  -

  • HealthLink ONLY serves residents from Bucks County or Montgomery County (Pennsylvania). Do not complete this application if you do not reside in either of these two counties.

  • County*
  •  -
  • Were you referred to us? If so, by whom? (Check one)

  • DENTAL INSURANCE INFORMATION

  • Do you have dental insurance?*

  • If you have dental insurance, you do not qualify to be a HealthLink patient. Do not complete this application.

  • EMPLOYMENT INFORMATION

  • You MUST provide us with either:

    • YOUR employment information - OR -
    • Employment information for your SPOUSE or domestic partner

    If you are not working and you do not have a spouse/domestic partner who is working, you do not qualify to be a patient.

    Do not continue this application. Instead, click here to view other resources for dental care that may be available to you.

     

    VETERANS: Please call us at (215) 364-4247 to discuss your application.

  • I am providing employment information for:
  • Type of Employment*

  • FINANCIAL INFORMATION

  • Do you own your home?*
  • Did you file a Federal income tax return last year?*

  • FAMILY INFORMATION

  • Are there children living in your household?*
  • Are you a single parent?*

  • Sex/Ethnic Origin Statement- Completing this section of the form is OPTIONAL. HealthLink welcomes patients of all backgrounds. This information will be used for statistical purposes only.

  • Gender
  • Ethnic Origin

  • Marital Status

  • Certification

    I certify that the information on this application and the financial Information provided is correct. I give permission to verify income from any or all of the sources provided. I understand that any false statement with regard to my finances, dependents, address, place of employment, insurances and who resides in my household will be cause for denial of services and dismissal from HealthLink services permanently. I understand that if I meet Healthlink's initial eligibility criteria I will be contacted to schedule an eligibility confirmation appointment. At the confirmation appointment, which I must be present for, I will recive final determination of my acceptance as a HealthLink patient. I know that a dental appointment can only be made at the completion of a satisfactory confirmation appointment.

  • Date*
     - -

  • Medication List

  • Medication List Key:

    #=Amt of tabs   RX=Prescribed Med    D/C=Discontinued Meds (Updated &Inital)

  • Rows

  • Patient Medical History

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.

  • 1. Are you in good health?*
  • 2. Have there been any changes in your health within the past year?*
  •  -
  • 8. Have you ever had any abnormal bleeding?*
  • 9. Do you bruise easy?*
  • 10. Have you ever required a blood transfusion?*
  • 12. Do you or have you ever used controlled substances?*
  • Women Only: Are you pregnant or think you may be pregnant?
  • Are you nursing?
  • Are you taking birth control pills?
  • Do you take bone density medicine?
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows

  • To Become A Patient at HealthLink, You Must Still Provide Us With These Documents:

    • Most recent 2 months of paystubs;
    • Completed federal tax return (Form 1040) & schedules, if applicable, for the current year;
    • Proof of residency, such as utility bill or signed rental lease; and
    • Photo ID (drivers license, passport, or work ID)

     

    You can fax copies of the documents to us at (215) 791-1907, email them to jsantiago@healthlinkdental.org, or mail them to us at:

    HealthLink Dental Clinic

    Attn: Patient Application

    444 N. York Road

    Hatboro, PA 19040

    You will not be accepted as a patient and will not be able to schedule your first appointment until we have all of these documents.

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