Donated Dental Care Reporting Form

General Information

All questions are required. Additional questions will appear based on your answers regarding donated dental care for children and adults.

Dental office/clinic name/location where care took place:

City where care took place:

Names of dentists that provided donated care:

Month/year the donated care took place:

Name of person filling out form:

Phone number:

Email:

Yes

Prefer not to answer

Event

Individual Patient