Florida Healthy Kids Incentive Form

To get your $10 Walmart gift card,

While showing active coverage, make sure to have the qualifying dental services:
Members age 6-14 years:

I had a sealant

Date of Service:

I registered for the DentaQuest member portal:

Yes

Member Information

First Name:

Last Name:

Date of Birth:

Mailing address:

City:

State:

Phone:

( ) -

If you have questions, please call DentaQuest toll free 888-696-7566.
TTY: 800-466-7566