Medical History Form
NC STATE MEDICAID
At present we don't accept payment plans.
Please only complete this form if you have medical insurance.
Medicare will not pay for this.
Must complete all paperwork within 30 days
Email is mandatory
FAQ: I have no insurance, and several teeth that need to be removed. Can you help me? No, because we are not supported by tax payers.
A: Please try a state funded organization like the dental school.
Thanks for submitting!