Javascript is required to load this page.
Page Loaded
English
Español
Hi please fill this form out if you are interested in receiving free dental care from UCSF student clinic. This is for children under the age of 15 that are uninsured or have no permanent dental provider.
Name (first name last name)
Best email to contact you
Best phone number to contact you
Preferred language
English
Spanish
Mandarin
Cantonese
Other
If other, please list language
Is your child under the age of 15?
No
Yes
Does your child have a regular dentist?
No
Yes
Maybe
Is your child uninsured?
No
yes
unsure
Our clinics are held the first Wednesday of every month at 5:30 pm. Would you be able to come with same-day of notice (in case of cancellation)?
Yes
No
Powered by Qualtrics