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ODA COVID-19 Emergency Provider Registry

In an effort to assist with COVID-19 efforts, the ODA is compiling a list of providers willing to see emergency patients in each county/component society.  If you would like to be included in these efforts, please complete the below form- thank you for your participation!

Please Note: By completing this sign up form, you allow the ODA to share the information provided with public officials/emergency rooms/public health entities/etc for the patient referral process. 
1.First Name(Required.)
2.Last Name(Required.)
3.Degree
4.Email(Required.)
5.Phone
6.Component Society(Required.)
7.Practice Model(Required.)
8.Practice Specialty (Required.)
9.What city is your practice located in?(Required.)
10.Emergency Patient Coordinator Contact (if different than dentist)
11.When are you available for emergency care?
12.Do you currently hold active hospital privileges/ are you currently credentialed to provide care in a hospital setting?(Required.)
13.Have you registered for the State Emergency Registry of Volunteers in Oregon? (Required.)
14.Any additional comments?