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VSDS MEMBER UPDATE FORM
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:
Office Name:
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(?)
Specialty:
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(?)
Office Mailing/PO Box:
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(?)
Office Physical Address:
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(?)
City:
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(?)
State:
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(?)
Zip Code
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(?)
Office Phone:
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(?)
Office Fax:
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(?)
Office County:
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(?)
Office Website:
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(?)
Dentist Name & Dentist Preferred Email:
(if staff completes, please ask dentist for preferred email)
First Name
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(?)
Last Name
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(?)
Suffix- Sr/Jr
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(?)
Degree: DMD/DDS
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(?)
Dentist's Preferred Email:
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(?)
Dentist's Home Address:
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(?)
City:
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(?)
State:
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(?)
Zip Code:
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(?)
Office Manager Name & Email
Please note that this will serve as a secondary contact for the VSDS.
Office Manager Name:
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(?)
Office Manager Email:
Click to add
(?)
Patient Care Services You Provide
Pain management used in your office:
Nitrous Oxide
Oral Medication
Full IV Sedation
Are you accepting NEW adult medicaid patients?
Yes
No
Accepting Limited Number of NEW Adults
Are you accepting NEW child medicaid patients?
Yes
No
Accepting Limited Number of NEW Children
Select any of the following services used in your office.
TMD Treatment
Dentures
Denture Same-Day Repair
Sleep Apnea
Care Credit
Post Treatment Payment Plans
Handicapped Accessible Office
Check the days you see patients in your practice.
Monday
Tuesday
Wednesday
Thursday
Friday
Add any further information we should know, or additional office locations:
Click to add
(?)
Member Center
Join / Renew
Member Update
Benefits of Membership
Endorsed Companies
Member Resources
News
First District Trustee Reports
Archived Newsletters
Evidence-Based Dentistry
Organization Governance & Documents
Strategic Plan
Constitution and Bylaws
Membership Directory
Staffing Your Practice
COVID-19
Events
Continuing Education Verification
Continuing Education
Special Smiles
VSDS State House Day
Vermont Dental Conference
Participants
Speaker Information
Sponsors
Exhibitors
About Us
VSDS Executive Board
VSDS Staff
Contact Us
Employment & Internships
For the Public
Find a Dentist
Community Dental Care Options
Find a Dental Clinic in VT
Frequently Asked Questions
Recruiting
Submit a Classified
Classifieds
Why Practice in Vermont?
"State":"VT"