General Information

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

Dentist office/clinic information

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1. Dentist office/clinic information

Contact Info

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2. Contact Info

Is the office/clinic a Medicaid provider?

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3. Is the office/clinic a Medicaid provider?

Was the donated care for an event or for an individual patient?

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4. Was the donated care for an event or for an individual patient?

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