Application

Thank you for your interest in Operation Restore Oral Health. Please fill out the Veteran application below.

Comments

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

Name(Required)

First Last

Marital Status(Required)

Gender(Required)

Date of Birth(Required)

Address(Required)

Address City State Zip

Email(Required)

Home Phone

Cell Phone

How did you hear about the OROH program?

Briefly describe your dental problems(Required)

How many natural teeth are remaining?

# of Upper Teeth(Required)

# Lower Teeth(Required)

Name of last Dentist & Phone:

Approximate date of last dental visit?

Please list other cities or how far you are willing to travel in order to get dental treatment:(Required)

Your Household: For each person include Name, Age, Relationship and Monthly Income(Required)

Total Monthly Household Income:(Required)

Are you able to work?(Required)

Your monthly employment income:(Required)

If YES, place of employment:

If NO, please explain why:

Is your spouse/significant other employed?(Required)

If no, please explain why:

If they are employed, Place of employment:

Spouse's/significant other’s monthly employment income:(Required)

SSI or SSDI Payments:

Monthly amount:

Year benefit began:

Social Security (retirement):

Monthly amount:

Year benefit began:

Unemployment/Workers Compensation:

Monthly amount:

Year benefit began:

Temporary Assistance to Needy Families (TANF):

Monthly amount:

Year benefit began:

Other Public Assistance:

Monthly amount:

Year benefit began:

Total Monthly Household Income:

Monthly amount:

If you are not receiving disability, have you ever applied?(Required)

Pension:(Required)

Total value of Savings:(Required)

Type of Investments/Assets:(Required)

Total value of Investments/Assets:(Required)

Do you receive Food Stamps?(Required)

Monthly amount:

Do you receive Medicaid benefits?(Required)

Medicaid #:

Do you have a Medicare Advantage Plan?(Required)

Do you have dental insurance?(Required)

Housing:(Required)

Own

Rent

Food (not including Food Stamps):(Required)

Utilities:(Required)

Phone:(Required)

Cable/Internet:(Required)

Credit card/Loan payments:(Required)

Medications/Medical Costs:(Required)

Out of pocket health insurance:(Required)

Life/Burial insurance:(Required)

Is there a car in the household?(Required)

If yes, Make/Model/Year:

Make:

Model:

Year:

Car payment:

Car insurance/Car expenses/Gas:

Other Monthly Expenses:

Total Monthly Household Expenses:(Required)

Are any family members able to contribute to costs of your dental treatment?(Required)

If yes, please explain:

Are any other sources available to help pay for dental care (i.e. churches, service organizations, other agencies, etc.)?(Required)

If yes, please explain:

Use this space to elaborate on any information not sufficiently explained in other areas: