Claim Your Health First Colorado or Child Health Plan Plus Additional Oral Health Benefits

Please briefly explain your license request below

Member Incentive Type

$20 Amazon Gift Card—Oral Health Risk Screening Form Within 90 Days of Enrollment $20 Amazon Gift Card—Preventive Visit Within 90 Days of Sign Up $20 Amazon Gift Card—Sealant Visit $20 Amazon Gift Card—two Preventive Dental Visits in a 12-Month Period $35 Amazon Gift Card—Opioid Use Assessment and Education Following Tooth Extraction

Member's Information

First Name

Last Name

Date of Birth

Guardian / Head of Household Phone Number

Mailing address

City

Zip code

Member ID Number

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

Date Member received care

PREVENTISTRY PULSE

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