The information in this form will be used for the VSDS Membership Directory.  In the dentist information section, the dentist's preferred email should be used (not automatically the general office email).  Please complete all fields.  

Office Name & Address:

Dentist Name & Dentist Preferred Email:

(if staff completes, please ask dentist for preferred email)

Office Manager Name & Email

Please note that this will serve as a secondary contact for the VSDS.

​Patient Care Services You Provide

Pain management used in your office:

Are you accepting NEW adult medicaid patients?

Are you accepting NEW child medicaid patients?

Select any of the following services used in your office.

Check the days you see patients in your practice.