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. 

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* 1. First Name

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* 2. Last Name

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* 3. Degree

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* 4. Email

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* 5. Phone

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* 6. Component Society

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* 7. Practice Model

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* 8. Practice Specialty 

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* 9. What city is your practice located in?

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* 10. Emergency Patient Coordinator Contact (if different than dentist)

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* 11. When are you available for emergency care?

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* 12. Do you currently hold active hospital privileges/ are you currently credentialed to provide care in a hospital setting?

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* 13. Have you registered for the State Emergency Registry of Volunteers in Oregon? 

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* 14. Any additional comments?

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