Smile Day 2017 Participation Form
Please complete this form by January 28th. For questions contact Karianna Simpkins at 215-563-5848 x21 or gksd@pccy.org. We will contact you soon to review the information on this form.
Dental Office Name *
Your answer
Contact Person's Name *
Your answer
Contact Person's Email Address *
Your answer
Dental Office Address Line 1 *
Your answer
Address Line 2
Your answer
City *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Best Time to Call *
Your answer
Fax Number
Your answer
What day or day(s) will you participate? (This is the week of spring break and kids are off of school).
How many children will you see? (With an average 25% Smile Day no show rate, we highly encourage overbooking). *
Your answer
What is the youngest age child/youth you will treat? *
Your answer
What is the oldest age child/youth you will treat? *
Care for preschool age children and teenagers is particularly needed
Your answer
What is the first appointment time? *
Your answer
What is the last appointment time? *
Your answer
How frequently should we appoint children? *
Example: one child every 15 minutes, three children every 20 minutes, etc.
Your answer
Will you shut down for lunch, and if so during what time?
Your answer
What type of care will you provide? *
Check all that apply.
Required
If any languages besides English are spoken at your office, please specify:
Your answer
Would you be willing to have language interpreters volunteer at your office on Smile Day? PCCY will recruit them. *
What public transportation comes to/near your office (subway, bus #, trolley #)? *
Your answer
What is the nearest major intersection and/or landmark for your office? *
Your answer
Do you accept any of the Medical Assistance plans? *
Note: Dentists provide free care to all children on Smile Day, but we’d like to let families know what insurance programs you accept.
Do you accept any of the CHIP plans? *
Note: Dentists provide free care to all children on Smile Day, but we’d like to let families know what insurance programs you accept.
Would you be willing to have a dental assistant high school student from Philadelphia's Oral Health Academy come shadow staff in your office on Smile Day? If so, indicate how many and someone will call you to discuss further details.
Your answer
Is there anything else you'd like us to know?
Your answer
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