Pediatric Dentistry and Community Oral Health

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Free Care Friday Application

Application Deadline: August 15, 2025

  • No Medicaid Insurance Accepted

  • For Ages 2-15 Years Old

First Name*
Last Name*
MRN
Date*
Dental Insurance?*
Phone (Primary)*
Phone (Secondary)
Street Address*
City/State/Zip Code*

  -

Date of Birth*
Age (must be between 2 and 15)
Gender
The School of Dentistry will only provide the following services. Please indicate which of these services you need.*

Current Medications and Allergies

Current Medications and Allergies
Medications Taken - List ALL medicines currently being taken, along with the dosage and frequency. For example: Aspirin 100mg, 1x per day.*
Do you have any allergies?*

Allergy Type(s) (select all that apply)

Please list allergy details

Health History

Health History
Cardiovascular
Hematology/Oncology
Endocrine

Last A1C result and date

Last glucose reading and date

Muscular/Skeletal
Nervous System
Immune System
Urinary System

List other kidney history

Respiratory
Digestive System
Eyes
Hearing
Behavioral

List other behavioral history

Other

List other history

Other Medical History

Other Medical History
Are you or have you taken bone strengthening drugs?
Are you presently under a physician's care?

Reason for last visit

Date of last visit

Blood Thinners

Blood Thinners
Are you taking blood thinners? (Warfarin/Coumadin, Aspirin, Pradaza, Xarelto, Plavix or Other)

What and when was your most recent INR?

List blood thinners taken

Attestation

Attestation
By submitting this form, I verify that the information provided is true and accurate, and I understand that clicking the "Submit Form" button below is the same as providing my digital signature.*