Free Dental Day | Smith Dental Care

Welcome to Free Dental Day!

Hosted by Smith Dental Care

This day of free dentistry is extended to you as a ministry of people coming together to give back to our community. It is our pleasure to take care of you! We will be offering one free service to those holding an appointment time. Those services include either an extraction, filling, or cleaning.

There are a few things we require for you to be admitted as a patient in this free event:

You must bring a valid photo ID.
You must be 18 years of age or older.
You must not be pregnant.
Please take all of your medications as normal.
You must not be on a blood thinner medication if an extraction is needed. Aspirin is generally OK.
Your blood pressure must be lower than 100 on the diastolic (lower) and under 200 on the systolic (higher) reading.
Avoiding caffeine and tobacco will increase your chances of having a blood pressure reading in our treatment range.
There will be no nitrous oxide or sedation offered, so if you have extreme dental fear, this may not be the best event for your treatment.

If an appointment is available you will be called with the phone number you provided. We cannot guarantee an appointment or an exact time. We will start calling alternates if appointments are available at 11:00 A.M. Those not present when their number is called will not be seen.

We have a limited number of appointments available today. Above all, we value your health so please understand that if we don’t feel it safe to do dental treatment on you, we cannot serve you in this event.

Thank you!

I have read and understood the guidelines of Free Dental Day, 2026.

Signed:

Date:

Patient Name:

Birthdate:

Phone Number:

SS#:

Are you a current patient at Smith Dental Care?YesNo

Does your doctor require you to take antibiotics
prior to dental procedures?YesNo

Do you have or have you ever had:

Are you pregnant?YesNo

Heart MurmurYesNo

Abnormal BleedingYesNo

Artificial JointsYesNo

Abnormal HeartYesNo

HepatitisYesNo

Rheumatic FeverYesNo

HIVYesNo

Mitral Valve ProlapseYesNo

Abnormal Blood PressureYesNo

Latex AllergyYesNo

Are you on a BLOOD THINNER of any kind?YesNo

If yes, what kind?:

Are you ALLERGIC to any drugs or medications?:

Any other physical conditions we should be aware of?:

Informed Consent

I authorize participating doctors and staff to perform any services necessary to diagnose my dental needs. Upon such diagnosis, I authorize participating doctors and staff to perform all recommended treatment mutually agreed upon by me. I understand that the use of anesthetics sometimes involves risks, and that I can ask for a complete recital of these risks.

I understand that all treatment or services performed or diagnosed by participating doctors and staff on February 7, 2026, Free Dental Day is FREE of charge and comes with NO WARRANTIES WHATSOEVER either expressed or implied. We reserve the right to refuse treatment of any person.

Signature:

*If an appointment is available you will be called with the phone number you provided. We cannot guarantee an appointment or an exact time. We will start calling alternates if appointments are available at 11:00 A.M. Those not present when their number is called will not be seen.*

If an appointment is available you will be called with the phone number you provided. We cannot guarantee an appointment or an exact time. We will start calling alternates if appointments are available at 11:00 A.M. Those not present when their number is called will not be seen.