Dental DaysPatient Sign up April 2025

Dental Days

Patient Sign up

April 2025

April 23rd-26th

First Name*

Last Name*

DOB*

telephone*

Phone

email*

Do You live in Coconino County?*

Coconino County

Elsewhere in Arizona

Outside Arizona

Tell us how heard about event*

Select all that apply and/or add your own.

Select or enter value

Have you taken part in Dental Days before?*

Have not taken part

Dec 2024

April 2024

July 2023

A Previous Mission of Mercy event

Select your ability to access dental care*

We want to focus on those in need, please let us know if you fit the following categories

I am unable to access dental care due to income and being uninsured or have AHCCCS/Medicaid insurance.

I have insurance and or finances and I can access care elsewhere.

If you wish, tell us more about your difficulty accessing care

What services do you need most?*

We may not be able to provide more than one service, but you can select more than one. (All Services are full for this event, You will be placed on a WAITING LIST)

Tooth Extraction

Filling

Cleaning

I consent to Sharing of my Personal Health information between Dental Days and NAU hygiene school*

Cleaning services will take place at NAU Hygiene school. We will share your information and they will reach out to schedule you. After being seen there, they will share your information back to us.

I consent

Cleaning Wait List*

WAIT LIST FOR CLEANING

Fill Wait List*

WAIT LIST FOR FILLINGS

Extraction Wait list*

WAITLIST FOR EXTRACTIONS

Anything else you need to tell us?

Send me a copy of my responses

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