Member Update

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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:

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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:

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VSDS MEMBER UPDATE FORM

Office Name & Address:

Dentist Name & Dentist Preferred Email:

Office Manager Name & Email

Patient Care Services You Provide

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VSDS MEMBER UPDATE FORM

Office Name & Address:

Dentist Name & Dentist Preferred Email:

Office Manager Name & Email

​Patient Care Services You Provide

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Patient Care Services You Provide