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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.
1.Contact(Required.)
2.Contact
3.Dentist Classification
4.Indicate any diagnosis or conditions you do not wish to be referred
5.If needed, are you willing to provide diagnostic procedures in your office?
6.Please indicate the number of patients and age groups you are willing to see per week/month/year
7.Do you have privileges at any hospitals?
8.Do you have access to interpretation services in your office?
Current Progress,
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