Provider Signup - DentalEmergencyCard

Personal Information

Office Details

Do you offer a Payment Plan?	Yes	No
Are you a member of the American Dental Association?	Yes	No
Do you treat children?	Yes	No
Do you treat disabled children or adults?	Yes	No
Do you have a hygienist?	Yes	No
Do have a Lab on Premises?	Yes	No
Do you accept Medicaid?	Yes	No

Do you take emergency visits?	Yes	No
Is your office equipped to treat wheelchair bound patients in their own wheelchair?	Yes	No
Is your office accessible via public transportation?	Yes	No
Is your office equipped with auxiliary aids and services (TTYIT DD, Braile, ASL, etc...)?	Yes	No
Does your office comply with OSHA requirements?	Yes	No
Does your office utilize proper infection control and barrier techniques?	Yes	No