When was the last time you saw a dentist about your teeth?

Would you like to see a dentist more frequently? 

If yes, why would you want to see a dentist more frequently? Please check all that apply 

What prevents you from getting the dental care you need? Please check all that apply


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What insurance do you have?  Please check all that apply:

Have you used the hospital emergency room for dental care? 

How frequently do you brush and/or floss your teeth?

What prevents you from brushing more frequently? Please check all that apply.



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  Do you need dentures? 

If Chatham County is planning to offer free or low-cost dental services and close to you and you could afford it, would you use these services?

If Yes, What day of the week would work best for you? Please check all that apply
What time of day would work best for you? Please check all that apply
Would you like us to contact you when we are ready to begin offering dental services? Yes or No

Would you be interested in giving us advice and input to plan our dental services? Yes or No - (If Yes, make sure name and contact number completed)