School-Based Dental Program Eligibility
Thank you for your interest in helping the North Carolina Dental Society Foundation (NCDSF) establish on-site pediatric dental services at Title 1 schools* across NC. Thanks to a grant from the Civic Local Foundation, NCDSF will provide four selected dentists with $5,000 to support the process. The ideal dentist/dental office, will be open to getting in front of school boards, identifying patients, and delivering care in their respective communities. The feedback from this pilot will drive best practices to improve oral health across the state.

Let's bridge the gap in oral healthcare for children in North Carolina!

Please ensure that the following eligibility criteria is met before continuing:
  • Must have a practice/work at a clinic within North Carolina
  • Willing to identify and work with Title 1 schools in North Carolina
  • Willing to provide services at no out of pocket charge to the patients and open to billing Medicaid/Health Choice or the patient's commercial insurance when appropriate.

*A Title 1 school is one that receives funding from the federal government that is used to support low-income students in their academic progress.
Email *
Application Questions
Name (First and Last) *
Phone Number *
1. Briefly explain your interest in piloting a school-based program.
 *

2. Are you willing to screen a minimum of two elementary/middle title 1 school(s) in the first year of receiving the grant funds? 

 *
Please List the School(s) you plan on working with (Please pick one that doesn't already have an oral health program)
3. Does your office accept Medicaid patients? *

4. Would you be willing to document the number of schools and children screened and provide this information to NCDSF on a quarterly basis? 

 *

5. Would you be willing to collect at least 4 testimonials of children provided with dental care? 

 *
6. Would you be willing to participate in a survey at the end of the one year pilot?  *
May we contact you about serving on a NC Dental Society board or committee in the future"? 
 *
Please check the following boxes in order to submit the interest form. *
Required
A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms