Complete this form to sign up with us to receive gas assistance for traveling to and from your dental appointments. You must provide either a phone number, email address, or both associated with your Zelle account.
You can learn more about Zelle and how to start accepting payments on their website (https://www.zellepay.com/get-started). Do not complete this form until you have set up your Zelle account through your banking app.
Once this form is completed, you can request assistance by filling out the gas request form to let us know when your appointment is.
By submitting this form you agree to the Assistance Agreement.
