Name:
Address:
Address 2:
City:
State:
Zip:
Office phone:
Fax:
Office e-mail checked frequently (dentist or staff):
Web site:
Are patient forms available on your web site? Yes
No
General dentist or specialist? General dentist
Specialist
If specialist, what type?
Office contact person:
Normal office hours (include lunch hours):
This is only for us to know when to better reach you.
Number of patients you would be willing to treat this school year?
(School year Oct.–June)
What age group of children are you willing to treat?
(Target pre-K through 3rd grade)
Is your office equipped with nitrous oxide? Yes
No
Do you or any staff members speak: Spanish
Vietnamese
Sign language
Other
Other languages spoken:
What type of procedures are you willing to provide? Preventative care
Restorations
Sealants
SSC
Pulpotomies
Extractions
Space maintainers
In-office sedation
Dental screenings
Dental screenings ONLY
O.R. (pediatric dentist)
Other
Other procedures you are willing to perform:
If you are able to perform O.R. procedures, please list the facilities you are credentialed at:
May we list you as a volunteer of the Save a Smile Program in printed material/literature/Web site? Yes
No
Preference on how or when patients are scheduled for dental appointments: