MAKE AN APPOINTMENT

DENTAL PROVIDER’S REFERRAL FORM

Dental providers, please print and fax our standard form. For confidentiality, we recommend using our secure fax cover sheet.

ELIGIBILITY REQUIREMENTS:

Little Lights Dentistry provides free dental care to children who:

  • Are between the ages of one and high school graduation;

  • Do not have Medicaid or dental insurance coverage; and

  • Have a family income at or below 250% of the federal poverty level

If your child meets these requirements, please request an appointment using the form below or call us at 772-223-9781.

REQUEST AN APPOINTMENT

Please note that submitting this form does not guarantee an appointment; it merely provides the necessary information to assess eligibility.