Sliding Fee Scale

How To:

1. Click on the appropriate download link below (English or Spanish)
2. The form will automatically download for completion or printing when you click the link.
3. Open the downloaded document with the free Adobe Reader (if you don't have Adobe Reader, you can get it here free!)
4. Fill out the entire form and save it. (Remember where you saved it!)
5. Return the form and required supporting documents to our office via email (office@twentyteeth.org). Be sure it is e-signed if returning via email. You can also print, sign and mail it to the address below or fax it to our office.

Sliding Fee Scale program policies and application are below.

The application can be completed electronically and emailed to our office, with supporting documentation. The application may also be printed and returned to our office .

CDHS recognizes that some families are unable to receive medical assistance and need to pay for their dental care out of pocket.

In an effort to assist theses families we have a sliding fee scale program that offers a discount on restorative services based on income.


Please refer to the table below to see if you qualify