Applicant's Name (first & last):
I am:
a parent or guardian
other relative
care provider
educator
the patient
Patient's Name (first & last):
(if different from applicant)
The patient is:
a minor
an adult
Organization's or School's Name:
(if applicable)
Street Address:
City:
State:
Zip Code:
E-mail:
Home Phone:
Cell Phone:
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I am interested in (check all that apply):
Seal! Michigan Dental Sealant Program
WIC & Immunization Clinic Fluoride Varnish Program
Head Start dental programs
mobile service to schools
mobile service to nursing homes
mobile service to private residence
dental cleanings
x-rays
fluoride treatments
oral hygiene instruction
referral to local dentist
other (specify below)
Are you a previous patient?
yes
no
Would you like to make an appointment?
yes
no
Time you prefer:
morning
afternoon
Day you prefer:
Wednesday
Thursday
Friday
How did you find out about us?
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