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Oral Health Assessment

Please fill out this form so we can help provide you with the best care. Complete one form for each member of your household who is a DentaQuest Plan member.

Member Information

Your DentaQuest Member ID number is the 9- or 10-digit number on the front of your card

Can we contact you using the email and phone number listed above?

Oral Health Assessment

Has it been more than 12 months since your last dental visit?
Do you have pain when eating cold, hot, or sugary foods?
Do you have a broken tooth or teeth?
Is your mouth dry?
Do your gums bleed when you brush or floss?
Have you had any gum (periodontal) treatments?
Do you wear dentures or partials?
Are you currently receiving radiation or chemotherapy?
Do you have a special need that makes it hard for you to see the dentist?
If yes, which one? (Select all that apply)
Are you pregnant?
Do you have a chronic health problem or illness that makes it hard for you to see the dentist?
If yes, which one? (Select all that apply)
Do you have any other type of problem that makes it hard for you to see the dentist? (For example, "I don't have a way to get to the dentist.")
Preventistry Pulse

PREVENTISTRY PULSE

A newsletter with tips and information to improve your oral health.

Dental benefits are provided by California Dental Network. California Dental Network does business as DentaQuest. Throughout this webpage, California Dental Network is referred to as DentaQuest. 

California Dental is licensed by the California Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act, which is one of the most comprehensive regulatory programs in the United States. Information about the Department of Managed Health Care and the plans they regulate can be found on their website at www.dmhc.ca.gov.

Medi-Cal Nondiscrimination Notice - Sacramento County
Medi-Cal Nondiscrimination Notice - Los Angeles County