Your Access to instant & affordable dental care.

Please provide the required information to determine your eligibility and proceed with enrollment.

Section 1
Personal Information
Full Name: *
Phone Number: *
Email Address: *
City: *
State: *
ZIP Code: *
Preferred Contact Method: *
Section 2
Residency and Identification
Household Size (including yourself):
Employment Status:
Do you receive any form of public assistance (e.g., SNAP, SSI, SSDI)?
If yes, please specify:
Section 3
Medicare/Medicaid and Insurance
Are you currently enrolled in: *
Do you receive dental benefits through your employer? *
If yes, please specify your insurance provider:
Do you have any other private or supplemental dental insurance? *
If yes, please provide details:
Section 4
Dental Needs and Services (select one or more)
Other:
Section 5
Dental History
When was your last dental visit? *
Do you currently have any dental pain or urgent needs?
If yes, please describe:
Do you have any ongoing dental conditions (e.g., gum disease, missing teeth, decay)? *
If yes, please explain:
Section 6
Additional Eligibility Factors
Are you a veteran or active-duty service member? *
Are you a senior (aged 65 or older)? *
Do you live with a disability that affects your ability to access dental care? *
Do you have dependents under 18 who also need dental care? *
Section 7
Household Coverage and Accessibility
Do any members of your household currently receive dental benefits or treatment under another program? *
If yes, please specify
Do you require transportation or mobility assistance to attend dental appointments? *
If yes, please describe:
Section 8
Consent and Privacy
Pick Appointment *

Privacy Note

Your information stays safe with us. We only share your details with licensed dental clinics participating in the Benefit Dental program.

frequently asked questions