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Dentist Registration Form


The purpose of this website is to help parents, medical providers, and others to find dentists who will care for individuals with special healthcare needs and for young children.


Please use this form to register electronically or you may print this form and fax to (804) 864-7783 or mail to:


Kami Piscitelli, R.D.H.
Virginia Department of Health - Division of Dental Health Office of Family Health Services
109 Governor St., 8th Flr., Richmond, VA 23219
Phone: (804) 864-7804


Please Note: You will need a valid email address to complete this form electronically; however, this email address will not be seen by the public. In addition, providing an email address will allow us to contact you regarding your account or upcoming continuing education courses related to providing dental care for people with special health care needs and very young children.

Dentist Information:

Dentist Name
First Name*:  MI:   Last Name*:


Suffix: (e.g., Jr, Sr, III)      Degree:
Office Address
Practice Name:
(if different from your name)
Primary Office Address:*
City:*
State:*
Zip:*
Phone:*
Clinical Hours:  Definition
Type of Practice*

Other Practice Type: 
Special Needs
Do you provide dental care for patients with the following conditions? Choose all that apply:
Age of Patients
Do you treat children?

Payment Method(s) Accepted
Do you accept Medicaid?


Do you have a sliding fee scale?
(A sliding fee scale is one that is based on the patient's ability to pay.)

Languages other than English Spoken in Your Office
Tip: Hold down the control key and click to select multiple items.

Other Languages:
Additional Comments



The following information is for internal use only and will not be published on the website



Dentist Information**
VA License*:

(ex: 0101415688)

Your Age:
Email*:
 
Please select the practice setting that best describe your work:

Dental Assistant Hours:   Definition
Dental Hygienist Hours:   Definition



 

Free Continuing Education Opportunity

In the future we hope to offer more tuition-free CE courses 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 these course:


If there are any other topics that would help you increase your ability to care for these special populations, you may provide this information in the Additional Comments box above, or by email.

* Indicates Required Field

** Indicates Internal use only

 

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