Application for Dental/Medical Services

Dental Applicants Only

  • I understand that fees for Dental services are separate from my initial visit fee.
  • I understand that Dental pricing may vary based on the services that I receive.
  • I understand that a 50% deposit is required at the time of scheduling my appointment.
  • I understand that there will be no refund of deposits towards my Dental appointment.
  • I understand that if I need to cancel an appointment, then I will call 24 hours ahead of time or sooner so that Bethesda may give that appointment time to someone else.
  • I understand that if I cancel an appointment on the same day as that appointment, or if I miss an appointment and do not call ahead, I will forfeit $20.00 from my pre-pay for that appointment.
  • I understand that I will be dismissed from Bethesda Dental Clinic if I miss my initial appointment or cancel any three appointments.
  • I understand that if I am over 10 minutes late, I will not be seen.

All Applicants

By clicking the Submit button below, I hereby declare that the above information is true and correct. I know that any false information could jeopardize my eligibility to receive medical attention at Bethesda Health Clinic.


Meet Patient Eligibility Requirements

  • Low income adult (age 18-64)
  • Dental-only applicants can be 65+
  • Employed or perform an important unpaid job, such as being a caregiver, volunteer or participant in a self-improvement program (e.g. education, rehabilitation, etc.)
  • Uninsured or underinsured
Prepare Your Documentation

Scan or photograph the following documents and save them as JPG, PNG or PDF files. (Each file must be 2Mb or less in size.)

  • A current government-issued photo ID
  • A recent headshot
  • Your most recent paystubs
  • Pages 1 and 2 of your latest filed tax return (form 1040)
  • If 65+ and applying for Dental-only, your Social Security/Disability Awards letter

Complete and Submit All 4 Online Forms

  • Application for Medical/Dental Services
  • Medical History
  • Waiver of Liability
  • Self-Sufficiency Matrix
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