Donated Dental Services Volunteer Form

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Donated Dental Services (DDS)

Volunteer for DDS

The Patients

The DDS Coordinator

The Volunteer Dentists

The Volunteer Laboraties

Lab Work & Referral to Specialists

When Treatment is Completed

Stories from volunteers

Volunteer Now (dentist)

Volunteer Now (laboratory)

Bridge/Campaign of Concern

Volunteer Now (dentist)

Please be sure to fill out the entire form (*Required Fields)

What type of patients would you consider treating? (Check all that apply.)

Disabled

Elderly

Medically Compromised

Disadvantaged Youth

Comments:

Is your office wheelchair accessible?

Yes

Do you have hospital(s) privileges?

Yes

Which hospital(s)?

*Are you a:

General Dentist

Specialist

Specialty:

*First Name:

*Last Name:

*Office Address:

*City:

*State:

*Zip:

*Daytime Phone:

FAX:

County

E-Mail:

State or Local Dental Association/Society/Component:

Check all organizations to which you belong:

American Dental Association

American College of Dentists

Academy of General Dentistry

American Association of Women Dentists

American Academy of Implant Dentistry

Hispanic Dental Association

Other

What initiated your decision to volunteer for the DDS program? (Check all that apply.)

Received a mailing

ADA publicity

AGD publicity

Dr. Gordon Christensen

A colleague who volunteers

A Dental Organization. Which Organization?

DentaCheques

Other

Name desired on recognition plaque

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