Waiver of Liability

APPLICATIONS   Waiver of Liability Name Title Choose One Mr. Ms. Mrs. Prof. Dr. Last Name * First Name * Middle Name Date of Birth * Email Address * Waiver of Liability for Treatment The Medical/Dental treatment provided by Bethesda Health Clinic, a charitable...

Self-Sufficiency Matrix

APPLICATIONS   Self-Sufficiency Matrix Company Title Choose One Mr. Ms. Mrs. Prof. Dr. Last Name * First Name * Middle Name Gender * Male Female Date of Birth * Email Address * Check one box for each category below. Choose the answer that is closest to your...

How to Apply Online

APPLICATIONS   How to Apply  Important All applications must either be completed online or be completed in-person by appointment only. Online Applicants Step 1  Meet Patient Eligibility Requirements Low income adult (age 18-64) Dental-only applicants can be 65+...

Medical History

APPLICATIONS   Medical History Phone Today's Date * Title Choose One Mr. Ms. Mrs. Prof. Dr. Last Name * Middle Name First Name * Date of Birth * Sex * Male Female Place of Birth (State or Country) * Marital Status * Single Married Divorced Separated Widowed...

Application for Medical/Dental Services

APPLICATIONS   Application for Dental/Medical Services Web Site Title Choose One Mr. Ms. Mrs. Prof. Dr. Last Name * First Name * Middle Name Street Address * City * Zip * Date of Birth * Sex * Male Female I'm applying for: Medical Services Only Dental Services...
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