Dental providers referral form

Dental providers, please print and fax our standard form. Consider using our confidential fax cover sheet for patient protection.


We provide free dental care for children and adolescents under the age of 18 who:

  • Are not covered by Medicaid, and
  • Have no dental insurance, and
  • Meet income eligibility requirements as defined by the Florida Department of Health

If you feel your child qualifies, please request an appointment using the form below or call us at the information provided on our Contact Us form.

If your child does not qualify for our program, please click here for more information.

Request an Appointment

This does not guarantee an appointment; it provides information to help us to determine eligibility.

Child's Name *
Child's Name
Parent or Guardian Name(s) *
Parent or Guardian Name(s)
Parent or Guardian Phone *
Parent or Guardian Phone
Secondary phone (if possible)
Secondary phone (if possible)