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Home
About
Community Impact
Board of Trustees
Staff
History
What We Do
Neighbors Feeding Neighbors
Care Van
In-school Mental Health Counseling
ISS & Mentorship
Get Involved
Employment Opportunities
Give
Guest Server Night
Holiday Fantasy
Mt Rainier Half Marathon
Volunteer
Contact
Donate
Sponsor a Neighbor
Senior Stories
Holiday Fantasy
Dental program Intake form
Dental Program
The RFWF Dental Program serves people living within the Plateau area. The Plateau is considered Enumclaw and the surrounding areas of Black Diamond, Buckley, Carbonado, Cumberland, Greenwater, South Prairie & Wilkeson. The Dental Program is for low-income patients who have a serious dental problem (such as pain or an abscessed or broken tooth) and no dental insurance (private or Medicaid coverage) or the financial means to pay for care at this time.
Size of Family
*
What is your household income before taxes
*
Must be under the 200% Federal Poverty Level shown below.
Number of Persons in Family/Household 1 $12,880 2 $17,420 3 $21,960 4 $26,500 5 $31,040 6 $35,580 7 $40,120 8 $44,660
Client Information:
Name
*
First
Last
Email
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Date of Birth
*
MM slash DD slash YYYY
How did you hear about the Dental Program?
*
Please mark any of the following:
*
The client has served in the military.
The client has received dental assistance from the Dental Van before
The client needs transportation assistance for the appointment.
The client has Medicaid.
The client has dental insurance.
None of the above
If you are the "client," please answer for yourself.
About when did the client receive care?
*
MM slash DD slash YYYY
Level of Urgency Questions:
1. Describe the problem
*
Trauma? Bleeding? Holes? Brown or black color? Broken teeth or stumps?
Possible Infection/Abscessed Tooth
Does the client have swelling of the face or neck? Large swelling by the tooth? Fever? Redness? Puss drainage around the tooth? Gum Boil?
Is the client losing sleep because of the pain?
Is the pain waking you up at night?
Has the client been to the doctor or emergency room for antibiotics/pain medication?
Check all that apply
On a scale of 1 to 10, how badly does the teeth/tooth hurt?
Please enter a number from
1
to
10
.
What makes your tooth hurt?
Hot
Sweet
Chewing on it
Check all that apply
Is the pain being controlled by over-the-counter medications such as Advil, Tylenol, Ambelsol, Orajel, clove oil, temporary filling material?
N/A
Yes
No
Client's Signature
*
I understand that if I am negligent and do not show up to the scheduled appointment, I render my eligibility to participate in the RFWF sponsored Dental Assistance Program.
The client understands that...
*
The Dental Assistance Program is for low-income patients who have a serious dental problem (such as pain or an abscessed or broken tooth) and no dental insurance (private or Medicaid coverage) or the financial means to pay for care at this time. I hereby accept these terms and authorize dental services and/or procedures that the dentist in his or her professional judgement are appropriate and necessary. This includes, but is not limited to the administration of local anesthesia and may include, if necessary, the extraction teeth. I understand the dentist providing care has not promised on-going dental care for me and has not assumed responsibility for ongoing dental care/treatment.
Name
This field is for validation purposes and should be left unchanged.