Volunteer Sign-Up Form
"start where you are, use what you have, do what you can"
Dentists for the Disabled and Elderly in Need of Treatment, Inc.
Your Full Name
Dental Office Address
Dental Office Phone Number (including area code)
Dental Office Fax Number (including area code)
Dental Office Contact Name
I am a
Oklahoma Board of Dentistry License Number
Please select population you feel most passionate about helping through D-DENT:
low-income, uninsured ELDERLY (over 60)
low-income, uninsured DEVELOPMENTALLY DISABLED
low-income, uninsured VETERAN
low-income, uninsured SPECIAL NEEDS
I would love to help restore the oral health of:
1 PATIENT per MONTH in my private practice
6 PATIENTS per YEAR in my private practice
4 PATIENTS per YEAR in my private practice
2 PATIENTS per YEAR in my private practice
1 PATIENT per YEAR in my private practice
I wish to volunteer for COMMUNITY DENTAL DAY
What type of dental work will you provide through D-DENT?
Fixed Prosthodontics (D-DENT pays for lab bill incurred)
Orthodontic (D-DENT pays for lab bill incurred)
Removable Prosthodontics (D-DENT pays for lab bill incurred)
My office is wheelchair accesible
Thank you for allowing us to help you make a difference, one smile at a time.
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