Give Smiles - Toothbrush Donation Question Title * 1. Dentist First and Last Name Question Title * 2. Office Name (Please note: for dentists with multiple practice locations, supplies will be sent to one location) Question Title * 3. Shipping Address (No P.O. Boxes) Question Title * 4. City Question Title * 5. State Question Title * 6. Zip Question Title * 7. County Question Title * 8. Phone Number (with area code) Question Title * 9. Email address to notify your office when toothbrushes are shipped (note: this may differ from the email used for Delta Dental of Iowa or DWP dental benefits communications). Question Title * 10. In-kind toothbrush donations require a dental education and/or dental screening component. In the box below, please describe the community event or engagement activity where you will educate children on oral health.Note: We are unable to donate toothbrushes for in-office patient appointments, parades, overseas mission trips, or activities that do not include a dental education component. Question Title * 11. Date(s) and location(s) of proposed outreach activity. Done