Love thy Neighbor Registration Form

Attention Veterans!

This year’s Annual Local Mission, Love Thy Neighbor is for VETERANS and will be held August 11, 2018 for qualified applicants.Love thy Neighbor is an annual event hosted by Drumright Dental Center to provide treatment to those who have no access to dental care, including fillings, extractions, cleanings, dentures and partials.

Military ID is required.

Apply Below!

Love Request

First Name *

Last Name *

Social Security Number *

This will be used to determine eligibility for the Love Thy Neighbor program.

Military Vet ID Number *

If you are applying as a military member, please enter your veteran ID number. You will be required to present your ID at our pre-screening events in July.

Date Of Birth *

Address

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

If your request involves an event, please enter its location.

Email Address *

Phone Number *

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Please note that e-mail is not a secure form of communication. Medical information placed here may not be confidential. Please use this form to send your contact information, and we will respond to your inquiry using a secure method. This form should not be used by children under the age of 18.

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