We are hoping to increase the availability of dental care in New Hampshire. We need your help to make sure we understand your needs. This survey has six questions and should take less than 5 minutes to complete. Thank you for your help!

1. Are you able to receive the dental care you and your family need?

Are you able to receive the dental care you and your family need? Yes

2. If yes, where do you and/or your family get dental care? (Check as many as apply)

If yes, where do you and/or your family get dental care? (Check as many as apply) Private dentist's office

Community Health Center

Community or hospital dental clinic

School-based clinic or program

Other (please specify)

3. If no, what are the reasons you are not able to receive care? (Check as many as apply)

If no, what are the reasons you are not able to receive care? (Check as many as apply) I am unable to pay for care

I can't find a dentist who offers a payment plan

I can't find a dentist who will take Medicaid

There is no dentist nearby

I can't find a dentist with office hours that are convenient

I can't find a dentist who will treat young children

I can't find a dentist who will treat a patient with disabilities

I need the services of an interpreter

Other (please specify)

4. In the past year have you or a family member gone to an emergency room for a dental problem?

In the past year have you or a family member gone to an emergency room for a dental problem? Yes

5. Where do you and your family usually receive other health care? (Check as many as apply)

Where do you and your family usually receive other health care? (Check as many as apply) Primary care physician's office

Community Health Center

Emergency Room

Walk-in Clinic

School-based clinic

Other (please specify)

6. What zip code do you live in?

What zip code do you live in?

1. Dental Care Consumer Survey

1. Are you able to receive the dental care you and your family need?

2. If yes, where do you and/or your family get dental care? (Check as many as apply)

3. If no, what are the reasons you are not able to receive care? (Check as many as apply)

4. In the past year have you or a family member gone to an emergency room for a dental problem?

5. Where do you and your family usually receive other health care? (Check as many as apply)

6. What zip code do you live in?