Please call for more information or to make an appointment.
Clinic Services Available
Save time waiting in the clinic! Print form(s) and complete using black ink. Then, fax to 402-441-8142 or bring the completed form(s) with you to your dental appointment. A child health history must be signed by parent or legal guardian.
A child must be accompanied by a parent or legal guardian or an Authorization Consent and Appointment of Agent Form will need to be completed and presented with the client.
Pregnant clients will need an Authorization to Treat (Pregnant Client) form signed by their physician for dental treatment. Print the form, have your physician complete and sign the form and bring the completed form with you to your appointment.
Complete one per household. Must be updated annually at minimum. Proof of household income must be provided at time of visit for eligibility of dental services. Full price dental fees will be charged if proof of income is not provided.
Complete one per patient. Update annually. Please bring a current list of your medications.
Complete only if the parent or legal guardian can’t bring the child to the appointment. The form must be completed to allow them to have another person aged 19 or older bring the child to their dental appointment.
Complete one per family.
Authorization to Treat (Pregnant Client) - Physician Signature Required(PDF, 106KB)
555 South 10th Street
Lincoln, NE 68508