Save a Smile

Denture Program - Screening Form

*This is not a guarantee of services until we are able to schedule an intake to be completed with Catholic Charities when funding and space is available. This information will be updated and added to our waiting list. We will contact you if/when we have funding and spots available for the next steps.

Save a Smile Screening Form

First name*

Last name*

Address

City*

Zip / Postal Code*

Birthday*

Month

Day

Year

Email*

Phone*

Do you have Medicaid?*

Yes

Do you have insurance?

Yes

Are you under a physician's care now?

Yes

Do you have a primary dentist?*

Yes

Are you on any blood thinner medication?*

Yes

Are you currently taking ANY medications?*

Yes

Are you pregnant or is there a possibility you may be pregnant?*

Yes

Have you ever worn dentures?*

Yes

If so, were they a full or partial set?

Full Set

Partial Set

N/A

If you previously wore dentures, how long ago? What happened to them?

What denture service do you believe you need?*

Full Set

Full Upper or Lower

Partial Upper or Lower

Will you be able to get transportation to the denture office?*

Yes

Is there anything we should know? (For example: no teeth left, only bottom teeth left, broken teeth, need teeth pulled, etc.)*

Catholic Charities of South Carolina

901 Orange Grove Road

Charleston, SC 29407

ccharities@charlestondiocese.org

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