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Dental Survey Form
Name
*
First
Last
*
Last
Gender
*
Female
Male
Date of Birth
*
Address
*
City
*
State
*
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
County
*
Home Phone
*
Cell Phone
*
Email Address
*
Ethnicity
*
African American
Asian/Pacific Islander
Caucasian/White
Hispanic
Native American
Other
If 'Other,' please explain here:
Please select the amount that best represents your ANNUAL household income:
*
Less than $10,000
$10,000 - $20,000
$20,000 - $30,000
More than $30,000
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.)
*
SNAP (food stamps)
SS
SSDI
SSI
WIC
Other
None of the above
Other (explain here)
EMERGENCY CONTACT
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:
*
FOR OFFICE USE ONLY
If you are human, leave this field blank.
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