Dentist Registration Form (printable version)



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Dentist Registration Form (printable version)

Please use this form to add your information to the website. Fax to (804) 864-7783 or mail to the address listed on the website. * Required Fields


First Name:* MI: Last Name:*




Suffix:         Degree: Virginia License Number:*

(e.g., Jr, Sr, III)

Primary Office

Practice Name:

(If different from your name)
Office Address:*
City:* State:* Zip:*
Phone:* # Clinical Hours/Week:

(Number of hours per week that you spend treating patients)



Second Office (if applicable)

Practice Name:


Office Address:*
City:* State:* Zip:*
Phone:* # Clinical Hours/Week:




Third Office

Practice Name:


Office Address:*
City:* State:* Zip:*
Phone:* # Clinical Hours/Week:


Type of Practice: Select whether you are a general dentist or specialist:


 General Dentistry  Orthodontics  Prosthodontics  Endodontics

 Pediatric Dentistry  Oral & Maxillofacial Surgery  Periodontics

 Other Other Practice:




ther

her Per, you may complete the survey online by clicking on Dentist Registration Form.

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her Per, you may complete the survey online by clicking on Dentist Registration Form. Special Needs: Do you provide dental care for patients with the following conditions? Choose all that apply:


  • Asthma

  • Autism

  • Behavioral/ADHD

  • Blindness

  • Cancer

  • Cardiovascular Diseases

  • Cerebral Palsy

  • Cleft Lip & Palate

  • Convulsive Disorders

  • Cystic Fibrosis

  • Deafness

  • Diabetes

  • Down Syndrome

  • Ectodermal Dysplasia

  • Hemophilia

  • Intellectual Disabilities

  • Muscular Dystrophy

  • Sickle Cell Anemia


Age of Patients:
Do you treat children?  Yes  No
If yes, beginning at what age?  0-3 years  4-6 years  7-10 years  11 years or older
Payment Method(s) accepted:
Do you accept Medicaid?  Yes  No If yes are you accepting new patients?  Yes  No
Do you have a sliding fee scale? (Based on the patient’s ability to pay)  Yes  No

List all Languages other than English spoken in your office:





**The following information is for internal use only and will not be published on the website


Dentist Information**
Your Age: Are you retired?  Yes  No

 

Please select the practice setting that best describes your work:


Private Practice  VDH public health clinic  Community health center  Military  Educator/Researcher  Jail or Correctional facility  Other
Dental Assistant Hours: Dental Hygienist Hours:

(Total number of hours of dental assistants (Total number of hours of dental hygienists

for all offices combined. For example, if for all offices combined. For example, if

you have two assistants who work you have two hygienists who work

35 hours each, enter 70.) 35 hours each, enter 70.)
Free Continuing Education Opportunity. We will be offering a tuition-free CE course regarding the care of children with special health care needs and very young children. Possible topics include an overview of special health care conditions, patient behavioral management techniques, and infant oral health assessment and prevention. Please indicate your level of interest in this course:
 Would definitely participate;  Might participate  Unlikely to participate

notify me of the next course date.


Please list any other topics that would help you increase your ability to care for these special populations:


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