7060 S. Yale Ave., Suite 707
Patient Application Request Form / Volunteer Dentist Form
The below form is for new patients requesting an application be mailed to their address -OR- Dentists interested in volunteering (Select ‘Yes’ for additional required fields)
**PATIENTS** THIS FORM IS NOT FOR SUBMITTING YOUR APPLICATION INFORMATION, OR ANY OTHER SENSITIVE MEDICAL INFORMATION, AND IS FOR SUBMITTING YOUR ADDRESS AND CONTACT DETAILS ONLY. WE APPRECIATE YOUR UNDERSTANDING.
Thank you – E.O.D.D.S. staff