Patient Intake

Begin Your Coordinated Dental Care Journey

Complete the intake form below. A Zaltivex care coordinator will review your submission and respond within 24 hours with next steps and care pathway options.

What to Expect

Your First Steps with Zaltivex

Submitting this form initiates your care coordination intake. Here is what follows after submission:

1

Intake Review

A coordinator reviews your submission within 24 hours and identifies the appropriate care pathway.

2

Initial Consultation Call

Your coordinator contacts you to confirm clinical details and discuss care options in full.

3

Provider Matching

We match your clinical needs with a qualified provider in your area and facilitate the appointment.

4

Coordinated Care Begins

Your coordinator remains with you through every stage, from first appointment through follow-up and completion.

Confidentiality Assurance

All information submitted through this form is handled in accordance with HIPAA standards. Your data is used solely for care coordination purposes.

Patient Intake Form

Tell Us About Your Care Needs

Please complete all required fields. The more detail you provide, the more effectively our team can match you with the appropriate care pathway and provider.

Communication Preferences

By checking this box, I agree to receive account notifications from Zaltivex. Message and data rates may apply. Message frequency varies. I understand I can opt out by replying STOP to any message, or request assistance by replying HELP. Consent is not required for purchasing products or services. My number will not be shared with third parties or affiliates.

By checking this box, I agree to receive marketing text messages from Zaltivex. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to cancel at any time. Consent is not required for purchasing products or services. My number will not be shared with third parties or affiliates.

I have read and agree to the Zaltivex Privacy Policy and Terms of Service.

Thank you, your information has been received. A Zaltivex care coordinator will review your submission and contact you within 24 hours with your care pathway options.