The Link Program

To help us better assist you, please complete the form below. Note that certain fields are required to ensure we have the minimum necessary information.

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Address

Street Address City Province Postal Code

Most Recent Dentist or Dental Clinic(Required)

If none, approximately how long ago was your last dental visit.

Do you have children?

Yes

Number of Children?

Current Employer

If not currently employed please write "none"

What type of coverage are you seeking?(Required)

I would like a payment plan

I am able to contribute partial costs

I am seeking full coverage

Please enter possible contribution amount

Are you currently experiencing any tooth pain or discomfort?(Required)

Please describe.

Do you have any dental anxiety or fears?

Yes

On a scale of 1-10, how nervous are you about the dentist (1=no fear, 10=extreme fear)

Is transportation to/from your dental appointment a concern for you at all?

Yes

Please share with us any details about your financial situation that may help us understand your need for assistance with dental care. We appreciate your openness and are here to support you in any way we can.(Required)

How did you hear about this program?

Name

This field is for validation purposes and should be left unchanged.