NEK Dental
Urgent care & treatment of specific dental problems in Glover, Vermont
Home
About the Dentist
Services Provided
Pricing & Payment
Insurances Accepted
Delta Dental
Medicaid & Green Mountain Care
All Other Insurance
Why choose us
Location
Clinic Dates & Updates
Appointment Booking
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Name
*
First
Last
(Legal name for documents and insurance processing)
Nickname / Preferred Name
(Which name would you like us to call you?)
Email
*
Phone Number
*
(Please include area code)
Can your above phone number exchange text messages directly with the dentist?
*
Yes
No
Which Dental Insurance do you need to process?
*
No Insurance / Fee for Service Patient
Delta Dental
Medicaid / Green Mountain Care
Other Insurance
Dental Insurance Number
(Providing this information will allow for faster processing)
Date of Birth
(This will allow us to check your insurance eligibility and coverage)
Are you experiencing any of these problems?
Pain
Infection
Broken tooth
Decay / Cavities
Esthetic / Cosmetic Issue
Concerned generally about dentition
Have not seen a dentist in a long time
Other
(Check all that apply)
Do you think you already know which treatment you may need?
Extraction
Filling
Crown
Root Canal
Denture adjustment
General exam and evaluation
Other
Not sure
(Check all that apply)
Which town are you located in?
Which appointment times do you prefer
Daytime
Late Afternoon
Evening
Weekend
(Check all that apply)
Where did you hear about our office?
Description of your dental concern / Your message
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