How to Apply

Patients must be 19 years of age or older and must live in East Tennessee to qualify for treatment

     3 steps must be completed to apply to become a patient at Keystone Dental

 

1. - DOWNLOAD & COMPLETE FORMS

          To save time, please download the forms at the bottom of the page, print and mail completed forms  to the clinic. If you can not download the forms, you may stop by the Clinic’s office to pick up copies of the forms.

 

2. - GATHER PROOF OF INCOME*

          Please mail ALL proof of income for your household which may include: gross wages, salary, tips, social security, pension, annuity, veteran’s benefits, alimony, child support, military family allotment, food stamps, and others.

* If proof of income is not provided for all members in your household, your application will not be processed.

 

3. – MAIL COMPLETED APPLICATION AND ALL REQUIRED PAPERWORK TO:

Keystone Dental

603 Bert Street, Box 12

Johnson City, TN 37601

 

—THEN WHAT?

After your completed application is submitted with all required documentation, it will be reviewed and the information verified. When your application is approved you will be called and given an appointment time for a “New Patient Exam”. At this time you will be informed of your co-payment amount.**

** All patients are charged on a sliding scale based on income.

DOWNLOAD FORMS HERE: