Share A Smile 2024 Volunteer Form
Giving kids an even bigger reason to smile! "Share A Smile" is an extension of the Give Kids A Smile (GKAS) program. The goal is to open up access to care for children who are uninsured or under insured. Thank you for your generosity and commitment to our local communities!
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What is your full name and title?
In what county do you serve?
What is the best email to reach you?
What is the name of your practice?
What is your office's street address?
What town is your office located? *
What is the office zip code? *
What is your office phone number? *
How many children can you commit to treating? *
Are you willing to treat patients with special healthcare needs? *
If so, what types of patients can you accommodate? (ASD, physical impairment, wheelchair, etc) *
Any specific preferences (patient's age, time of day, sedation modalities, etc.) *
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