DCDS Foundation DC Dental Cares Pro Bono Program Sign Up Form

Thank you for your interest in participating in the DC Dental Society Foundation's DC Dental Cares Pro Bono Program. This program is being administered in partnership with Catholic Charities Health Care Network (CCHCN).

Please complete this form and representative of CCHCN will be in contact with you to provide additional program details.

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* 1. Contact

First Name

Last Name

Address 1

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Contact

Office manager or point of contact person

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* 3. Dentist Classification

General Dentist

Endodontist

Oral and Maxillofacial Surgeon

Orthodontist

Pediatric Dentist

Periodontist

Prosthodontist

Other (please specify)

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* 4. Indicate any diagnosis or conditions you do not wish to be referred

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* 5. If needed, are you willing to provide diagnostic procedures in your office?

Yes

If yes, please indicate:

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* 6. Please indicate the number of patients and age groups you are willing to see per week/month/year

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* 7. Do you have privileges at any hospitals?

Yes

If so, where?

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* 8. Do you have access to interpretation services in your office?

Yes

If yes, please indicate what languages?