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.

2017 FEDERAL Poverty Guidelines
Size of Family	Gross Annual Family Income	200% of Gross Annual Family Income	Gross Monthly Income & 200%	Approx. Hourly Income & 200%
1	$12,060	$24,120	$1,005-$2,010	$5.80 - $11.60
2	$16,240	$32,480	$1,353 - $2,707	$7.81 - $15.62
3	$20,420	$40,840	$1,702 - $3,403	$9.82 - $19.63
4	$24,600	$49,200	$2,050 - $4,100	$11.83 - $23.65
5	$28,780	$57,560	$2,398 - $4,797	$13.84 - $27.67
6	$32,960	$65,920	$2,747 - $5,493	$15.85 - $31.69
7	$37,140	$74,280	$3,095 - $6,190	$17.86 - $35.71
8	$41,320	$82,640	$3,443 - $6,887	$19.87 - $39.73
Add for each additional	+4,180	+8,360	+348 - $697	+$2.01 - $4.02

Client Information:

Name*

First Last

Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Date of Birth*

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?*

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 value between 1 and 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?

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.

Comments

This field is for validation purposes and should be left unchanged.

Dental Program

Client Information:

Level of Urgency Questions:

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