Health Care Home Dental Services Patient Dismissal Feedback Form Call 801-587-6453 You must have JavaScript enabled to use this form. First Name * Last Name * Date of Birth * Email Address * Phone Number Which clinic were you receiving care from? * Select a clinicGreenwoodLibertySt. GeorgeOgdenRose ParkMobile OutreachWakaraSouth MainUH DentalFaculty Practice Please explain why you believe your dismissal was unfair. * Leave this field blank
