Dental Survey Form

Name *

First

Last *

Last

Gender *

Female

Male

Date of Birth *

Address *

City *

State *

Zip *

County *

Home Phone *

Cell Phone *

Email Address *

Ethnicity *

If 'Other,' please explain here:

Please select the amount that best represents your ANNUAL household income: *

Household Size *

Number of people under 21 *

Are you or a family member covered by SoonerCare? *

Yes

No

Do you have dental insurance? *

Yes

No

Are you or a family member receiving government assistance? (Please check all that apply.) *

Other (explain here)

Name *

First

Last Name *

Last

Relationship *

Phone Number *

When was the last time you visited a dental office? *

Please explain what dental problems you are currently having: *