If you answered yes to the qualification questions please print the following and bring it into or mail to (the post office only delivers mail to the PO Box)...
Corner Stone Family Dental
Attn: Dental Grant
3 E Center St
PO Box 307
Sugar City, ID 83448
Name______________________ Date_____________________
Number in Family_____________ Yearly income______________
Do you have dental insurance or Medicaid? Yes/No
What is the nature of your dental problem?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Do you have any health problems with your heart, lungs, liver, kidneys, etc... that could interfer with dental treatment?
___________________________________________________________
___________________________________________________________
List all medication you are taking.
___________________________________________________________
___________________________________________________________
___________________________________________________________
How may we contact you and what times are best during the day to contact you?
___________________________________________________________
