Give Kids a Smile Day - Dental Hygienist Volunteer Form

Please send the attached form back to ADHA Central Office after your activities are completed.  Our address is 444 North Michigan Avenue, Suite 3400, Chicago, IL, 60611 and our fax number is (312) 467-1806.  If you have any questions, please contact us at 1 (800) 243-2342, extension 240. Thank you.
 
I worked on "Give Kids a Smile Day" on a volunteer basis with my employer dentist and staff ________

I worked on "Give Kids a Smile Day" on a volunteer basis with other dental hygienists __________

Number of hours worked ___________

Number of children seen ___________

Number of prophys performed ___________

Number of sealants placed ___________

Number of fluoride treatments ____________

Number of oral health screenings performed ___________

Other work performed
 
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