Snake River Community Clinic

Patient Name *

Date of Birth *

Please list dental care needs: *

When would you like to be seen? *

next available

urgent/ I am in pain.

non-urgent

Phone number *

Do you have insurance? *

Please choose the range that best describes your household monthly income: *

less than $1,133

between $1,134-$2,095

between $2,096-$2,831

over $3,397

other

* Required field