Kare Mobile Appointment Request Scheduler

1
Welcome to Kare Mobile! Are you an existing patient?
YESNO
2
Greetings,

Please call 1-800-787-2812 to schedule a follow-up visit with Kare Mobile. If you are not an existing patient, please click on the next button to continue. Thank you

Click here to return to our website.
3
Please provide us with your first name?* This field is required.
4
Hello {first_name}, what is your last name?* This field is required.
5
Email Address
example@example.com
6
Phone Number* This field is required.
7
{first_name}, please enter the zip code where you would like to be seen?* This field is required.
8
Appointment Zip Code : {zip_code}
9
{first_name},

We appreciate your interest in our services! We are constantly working to expand our serviceable areas, and {zip_code} is not currently one that we serve. If you click "Next" to continue, we will notify you as soon as your area becomes available for service.

Cheers,

Kare Mobile
10
{first_name}, would you like to enter another zip code?
YesNo
11
{first_name}, enter the location where you would like to have your appointment?* This field is required.
Street Address
Street Address 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
{first_name} would you like a cleaning? A one hour cleaning with a dental hygienist. Our licensed dentist may be teleconferenced in to conduct a tele-dentistry exam as needed.
YESNO
13
{first_name},

Based on the information you’ve supplied, you are booking a 60-minute cleaning appointment with a dental hygienist. Our licensed dentist will also be available to teleconference with you, should the need arise. Click next to continue.
14
Perfect! When did you have your last cleaning?
0 - 6 Months Ago
6 - 12 Months Ago
12+ Months Ago
15
{first_name},

Based on the information you’ve supplied, you are booking a 60-minute appointment with a dental assistant who will teleconference in with our licensed dentist to help diagnose your needs. Your appointment with our dentist will be scheduled for another day once your needs have been assessed at this initial appointment. Click next to continue.
16
{first_name}, which time of day do you prefer to be seen?
Mornings ( 9AM - 11AM )
Afternoons ( 12PM - 4PM )
17
Cleaning AppointmentBased on the information you’ve supplied, you are booking a 30-minute cleaning appointment with a dental hygienist. Our licensed dentist will also be available to teleconference with you, should the need arise.
18
{first_name} you have chosen a cleaning appointment set for {cleaning_appointment1} is this correct?
YESNO
19
Dental AppointmentBased on the information you’ve supplied, you are booking a 60-minute appointment with a dental assistant who will teleconference in with our licensed dentist to help diagnose your needs. Your appointment with our dentist will be scheduled for another day once your needs have been assessed at this initial appointment.
20
{first_name} you have chosen an appointment to see a dental hygienist on {dental_appointment2} is this correct?
YESNO
21
Date Of Birth?* This field is required.
Date of Birth
Month
Day
Year
22
Thank you {first_name}, what is your current mailing address?* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
23
Gender* This field is required.
Female
Male
24
Medical history, please check all that apply* This field is required.
Anemia, Sickle Cell Disease
Arthritis, Muscle, Bone, Joint Problems
Asthma, or Breathing Problems
Brain or Nervous System Problems
Cancer, Cancer Treatment
Diabetes
Heart Problems
Hemophilia, Excessive Bleeding, Bruising Easily
High Blood Pressure
HIV , Aids
Kidney Disorders
Pregnant or Possibly Pregnant
Stomach or Intestinal Problems
Transfusion Receiving Blood Products
Tuberculosis
None of the above
25
{first_name} do you have any drug allergies?* This field is required.
YesNo
26
{first_name} please provide your drug allergies below.Separate drug allergies with commas. ie; Penicillin, Acetaminophen, etc....
Drug Allergies
27
{first_name} are you currently taking any medications?* This field is required.
YesNo
28
Please list any current medications you are taking.Separate medications with commas. ie; Ibuprofen, Acetaminophen, etc....
29
Please check all that apply* This field is required.
Mouth Sores
Fever Blisters
Bleeding Gums
Cavities
Dry Mouth
Sensitive Teeth
Broken Teeth
Smoking
Grinding
Jaw Joint Pain
None of the above
30
{first_name} what would you like to be treated for?
Crown or Cap
Denture or Partial
Extraction - Front Tooth
Extraction - Back Tooth
Filling
Root Canal - Front Tooth
Root Canal - Back Tooth
None of the above
31
{first_name} do you have dental insurance?* This field is required.
YesNo
32
No problem, please provide an answer to the following statement, I hereby acknowledge by not having dental insurance, my dental visit will be paid entirely out of pocket.
Yes, I understand. No, I can not.
33
Take a photo of the FRONT of your insurance cardBe sure to include ALL FOUR CORNERS of the card
34
Take a photo of the BACK of your insurance cardBe sure to include ALL FOUR CORNERS of the card
35
Choose your insurance provider
Aetna Better Health
American Worker
Anthem
Blue Anthem
Blue Cross
CareSource
Cigna Dental
Delta Dental
Dental Care Plus
DentaQuest
Dentemax
Guardian
Humana
Humana CareSource Medicaid
Kentucky One Health
Medicare
MetLife
Mutual of Omaha
Passport
United Concordia
United Health Care
Wellcare
Other
36
{first_name}, please enter your {insurance_provider} Member ID number?Please note this is different from your group ID number
37
{first_name}, now enter your {insurance_provider} Group ID number?
38
Are you currently experiencing any pain?* This field is required.
0 - No pain
3 - Slight pain
5 - Moderate pain
7 - Severe pain
10 - This is an emergency!!!
39
{first_name},

We are sorry to hear you are experiencing a great deal of pain. We recommend visiting your local emergency room as soon as possible.

Kind Regards,

Kare Mobile
40
Confirm Today's Date* This field is required.
Date
Month
Day
Year
41
Terms & Conditions* This field is required.
42
Full Name* This field is required.
First Name
Last Name
43
Signature* This field is required.
Clear
44
Please verify that you are human* This field is required.
45
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Todo
In Progress
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