Welcome to CASG

Welcome Atlanta!
Please complete the form below, if you have any questions email us at CASG@kare.mobi
Are you 18 years old or older?

YesNo
Unfortunately,

In order for us to proceed with your apppointment scheduling request, you must be 18 years of age or older. Please contact a parent or guardian to complete this form. Thank You.

Sincerely,

Oral-B & Kare Mobile
Choose screening location ?
Choose screening date ? ATL, GA
Choose screening date ? NyC, NY
How many children will need a screening today? Fri, GA
How many children will need a screening today? Sat, GA
How many children will need a screening today? Sat , ATL
How many children will need a screening today? Fri , NYC
How many children will need a screening today? Sat , NYC
Patient #1 Appointment Time
Atlanta, GA | #C1 | FRI
Atlanta, GA | #C1 | SAT
AtlantaX, GA | #C1 | FRI
AtlantaX, GA | #C1 | SAT
New York City, NY | #C1 | FRI
New York City, NY | #C1 | SAT
Patient #2 Appointment Time
Atlanta, GA | #C2 | FRI
Atlanta, GA | #C2 | SAT
AtlantaX, GA | #C2 | FRI
AtlantaX, GA | #C2 | SAT
New York City, NY | #C2 | FRI
New York City, NY | #C2 | SAT
Patient #3 Appointment Time
Atlanta, GA | #C3 | FRI
Atlanta, GA | #C3 | SAT
AtlantaX, GA | #C3 | FRI
AtlantaX, GA | #C3 | SAT
New York City, NY | #C3 | FRI
New York City, NY | #C3 | SAT
Patient #4 Appointment Time
Atlanta, GA | #C4 | FRI
Atlanta, GA | #C4 | SAT
AtlantaX, GA | #C4 | FRI
AtlantaX, GA | #C4 | SAT
New York City, NY | #C4 | FRI
New York City, NY | #C4 | SAT
Patient #5 Appointment Time
Atlanta, GA | #C5 | FRI
Atlanta, GA | #C5 | SAT
AtlantaX, GA | #C5 | FRI
AtlantaX, GA | #C5 | SAT
New York City, NY | #C5 | FRI
New York City, NY | #C5 | SAT
Patient #6 Appointment Time
Atlanta, GA | #C6 | FRI
Atlanta, GA | #C6 | SAT
AtlantaX, GA | #C6 | FRI
AtlantaX, GA | #C6 | SAT
New York City, NY | #C6 | FRI
New York City, NY | #C6 | SAT
Parent or Legal Guardian Info
Relationship to patient(s) ?
Parent or Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient #1 Information
Patient #1 | Full Name

First NameLast Name
Patient #1 | D.O.B.

MonthDayYear
Date
Patient #1 | Gender
Patient #1 | Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does Patient #1 have any drug allergies ?

NoYes
Please provide Patient #1 drug allergies
Is Patient #1 currently taking any medications ?

NoYes
Please list any current medications for Patient #1
Dental History
Is Patient #1 currently experiencing any pain ?
Patient #1 | Dental History, Please check all that apply*

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient #1 brush their teeth daily ?
Which toothpaste does Patient #1 use most ?
How often does Patient #1 visit a dental office ?
Patient #2 Info
Patient #2 | Full Name

First NameLast Name
Patient #2 | D.O.B.

MonthDayYear
Date
Patient #2 | Gender
Patient #2 | Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does Patient #2 have any drug allergies ?

NoYes
Please provide Patient #2 drug allergies
Is Patient #2 currently taking any medications ?

NoYes
Please list any current medications for Patient #2
Dental History
Is Patient #2 currently experiencing any pain ?
Patient #2 | Dental History, Please check all that apply

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient #2 brush their teeth daily ?
Which toothpaste does Patient #2 use most ?
How often does Patient #2 visit a dental office ?
Patient #3 Info
Patient #3 | Full Name

First NameLast Name
Patient #3 | D.O.B.

MonthDayYear
Date
Patient #3 | Gender
Patient #3 | Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does Patient #3 have any drug allergies ?

NoYes
Please provide Patient #3 drug allergies
Is Patient #3 currently taking any medications ?

NoYes
Please list any current medications for Patient #3
Dental History
Is Patient #3 currently experiencing any pain ?
Patient #3 | Dental History, Please check all that apply

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient #3 brush their teeth daily ?
Which toothpaste does Patient #3 use most ?
How often does Patient #3 visit a dental office ?
Patient #4 Info
Patient #4 | Full Name

First NameLast Name
Patient #4 | D.O.B.

MonthDayYear
Date
Patient #4 | Gender
Patient #4 | Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does Patient #4 have any drug allergies ?

NoYes
Please provide Patient #4 drug allergies
Is Patient #4 currently taking any medications ?

NoYes
Please list any current medications for Patient #4
Dental History
Is Patient #4 currently experiencing any pain ?
Patient #4 | Dental History, Please check all that apply

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient #4 brush their teeth daily ?
Which toothpaste does Patient #4 use most ?
How often does Patient #4 visit a dental office ?
Patient #5 Info
Patient #5 | Full Name

First NameLast Name
Patient #5 | D.O.B.

MonthDayYear
Date
Patient #5 | Gender
Patient #5 | Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does Patient #5 have any drug allergies ?

NoYes
Please provide Patient #5 drug allergies
Is Patient #5 currently taking any medications ?

NoYes
Please list any current medications for Patient #5
Dental History
Is Patient #5 currently experiencing any pain ?
Patient #5 | Dental History, Please check all that apply

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient #5 brush their teeth daily ?
Which toothpaste does Patient #5 use most ?
How often does Patient #5 visit a dental office ?
Patient #6 Info
Patient #6 | Full Name

First NameLast Name
Patient #6 | D.O.B.

MonthDayYear
Date
Patient #6 | Gender
Patient #6 | Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does Patient #6 have any drug allergies ?

NoYes
Please provide Patient #6 drug allergies
Is Patient #6 currently taking any medications ?

NoYes
Please list any current medications for Patient #6
Dental History
Is Patient #6 currently experiencing any pain ?
Patient #6 | Dental History, Please check all that apply

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient #6 brush their teeth daily ?
Which toothpaste does Patient #6 use most ?
How often does Patient #6 visit a dental office ?
FINAL BREAK POINT
Insurance Info
Do you have dental insurance ?
Choose your insurance provider
Please enter your {insurance_Co} member ID number
Please enter your {insurance_Co} group ID number
Confirm today's date

MonthDayYear
Date
Terms & Conditions
Signature*

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Patient #1 Appointment Time

Patient #2 Appointment Time

Patient #3 Appointment Time

Patient #4 Appointment Time

Patient #5 Appointment Time

Patient #6 Appointment Time

Parent or Legal Guardian Info

Patient #1 Information

Dental History

Patient #2 Info

Dental History

Patient #3 Info

Dental History

Patient #4 Info

Dental History

Patient #5 Info

Dental History

Patient #6 Info

Dental History

FINAL BREAK POINT

Insurance Info

Terms & Conditions