GKAS – Smile Factory

GKAS - Smile Factory Registration

Clinic Name(Required)

Clinic Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name(Required)

First Last

Contact Email(Required)

Contact Phone Number(Required)

Number of children you will treat:(Required)

List the age range of children you will treat:(Required)

List examples of cases you will take (please be very specific):(Required)

List examples of cases you will NOT take (please be very specific):(Required)

Other notes for referring dental offices (for example, “The referring clinic must send us each child’s radiographs, treatment notes, etc….).(Required)

Please list the full names of the dentists who will be volunteering for the Smile Factory (Last Name, First Name):(Required)