DENTAL PROFESSIONALS SIGNUP FORM March 6-7, 2020 Footbridge Veterans Dental Clinic at 1st Christian Church, King, NC
Last Name: *
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First Name: *
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Profession:
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Specialty:
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Would like to volunteer: (Check all that apply) *
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I prefer to do: (What do you want to do at clinic?)
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Additional Notes or Comments:
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Home Street Address:
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Address Line #2:
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City:
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State:
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Zip Code:
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Email address: *
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Primary Phone:
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Cell Phone: *
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Best way to reach you with info/updates:
Full Name:
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License Number:
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State of Issuance:
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DEA Number:
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Professional Liability Carrier:
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Will your current professional liability carrier cover this volunteer work?
Dentist, would you be willing to provide care for "Post Clinic Emergency Follow Up?"
If "Yes" - please provide your office number:
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