Your Name *

First Name

Last Name

Phone *

(###)

###

####

Are you interested in any special services?

We'll use this to calculate your assessment, but you can always change your mind later.

Free sedation dentistry

Family-friendly dentistry

Whole health dentistry

Something else – Explain in comments below.

Who is this assessment for? *

If you're filling this out for someone else, add their name(s) and age(s) in the comments below.

Myself

My spouse, child, or another person I care for

My whole family (all adults and children)

When was your last dental hygiene visit? *

If you're filling this out for multiple family members, add their last visits in the comments below.

6 months ago or less

Between 6 months and 1 year ago

More than 1 year ago

Never or not sure

What type of dental benefits do you have? *

If you have multiple providers, add them in the comments below.

I'll provide my benefits information below

Contact me to verify my benefits information or discuss coverage

Government-sponsored supplementary benefits

No insurance or benefits coverage

Policy holder's birth date

MM

DD

YYYY

Declaration and authorization *

By submitting this form, I declare that the included personal information is my own, or I am authorized to provide it as the spouse, parent, guardian, or authorized caregiver of the person who it belongs to. I authorize Friends and Family Dental Health to use this information to conduct a dental treatment cost assessment and contact me with the results.