Pediatric Dentistry and Community Oral Health

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Free Care Friday

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Free Care Friday Application

Application Deadline: July 17, 2026

No Medicaid Insurance Accepted
For Ages 2-15 Years Old

First Name*
Last Name*
MRN
Date*
Dental Insurance?*	Yes No
Phone (Primary)*
Phone (Secondary)
Street Address*
City/State/Zip Code*	City State Zip -
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.*	Cleaning Fillings Silver Caps Extractions Oral Cancer Screening
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?*	Yes No Allergy Type(s) (select all that apply) Drug allergy Food allergy Insect allergy Latex allergy Pet allergy Pollen allergy Other Please list allergy details
Health History Health History
Cardiovascular	Heart disease High/Low blood pressure Pacemaker Mitral valve prolapse Heart murmur Heart valve replacement Heart stent Other
Hematology/Oncology	Anemia Excessive bleeding Cancer Sickle Cell disease
Endocrine	Diabetes Last A1C result and date Last glucose reading and date
Muscular/Skeletal	Rheumatoid Arthritis Osteoarthritis Joint Replacement
Nervous System	Seizures Cerebral Palsy
Immune System	HIV+ AIDS Lupus Scarlet fever Rheumatic fever
Urinary System	Kidney Disease Other List other kidney history
Respiratory	Asthma Chronic bronchitis COPD Tuberculosis Cystic Fibrosis
Digestive System	Ulcers GERD Hepatitis
Eyes	Vision loss Wear glasses Wear contacts
Hearing	Hearing loss
Behavioral	ADHD Autism Other List other behavioral history
Other	Organ transplant Radiation treatment Tobacco - Smoking Tobacco - Vape Tobacco - Dip Tobacco - Chew Other List other history
Other Medical History Other Medical History
Are you or have you taken bone strengthening drugs?	Yes No
Are you presently under a physician's care?	Yes No 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)	Yes No 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.*	Yes, I agree No, I disagree