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

Comments:

Is your office wheelchair accessible?

Do you have hospital(s) privileges?

Which hospital(s)?

*Are you a:

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:

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

Name desired on recognition plaque