New Patients (Mobile Clinic)

New Mobile Clinic Patient Information Form

Our DIVA Mobile Clinic service provides state-of-the-art mobile dental services to seniors living in a long-term healthcare facility. Please fill out this form to get started!

For regular in-office or home visit appointments, please use the In-office/Home-visit Appointment Request form.



You may review our policies as well. Thank you for your cooperation.

  1. Notice of Privacy Practices
  2. Patient Acceptance and Financial Policy