Submit Information for the Dental Directory - HOH-SC.org

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SC Dental Directory

Submit Information for the Dental Directory

* required sections

Name *
First Name:	MI:	Last Name:	Suffix:	Degree:

Primary Office *
Address:
City:		State:		Zip:
County:		Front Desk Telephone:		Fax:
Doctor's Phone:		Email:

Second Office
Address:
City:		State:		Zip:
County:		Front Desk Telephone:		Fax:
Doctor's Phone:		Email:

Third Office
Address:
City:		State:		Zip:
County:		Front Desk Telephone:		Fax:
Doctor's Phone:		Email:

Fourth Office
Address:
City:		State:		Zip:
County:		Front Desk Telephone:		Fax:
Doctor's Phone:		Email:

Type of Practice *
General Dentistry	Pediatric Dentistry	Orthodontics
Oral Maxillo Facial Surgery	Prosthodontics	Periodontics
Other: If other please specify:

Special Needs *
For patients with the following conditions, please check the categories you would provide routine dental services:
Asthma	Cystic Fibrosis	Blindness
Autism	Cancer	Deafness
Cardiovascular Diseases	Diabetes	Muscular Dystrophy
Cleft Lip & Palate	Ectodermal Dysplasias	Down Syndrome
Cerebral Palsy	Hemophilia	Mental Retardation
Convulsive Disorders	Sickle Cell Anemia	Behavioral Problems
Other:

Age of Patients
Yes	No	Do you treat children?
If yes, beginning at what age?
Yes	No	Do you treat adolescents?
Yes	No	Do you treat adults?

Outside of Office
Yes	No	Do you treat patients outside of your office, such as nursing homes, or private homes of the home bound?
Yes	No	Do you treat children at hospital facilities under general anesthesia?

Payment Method(s) accepted:
Preferred Dental Insurance:
Medicaid	Cash	Discover
American Express	Visa	Master Card
Insurance with balance billed to patient
Other:

Accessibility:
Free parking	Pay parking	Wheelchair accessible
Evening hours	Saturday hours	Special hours by appointment only

Languages other than English:
Spanish	Vietnamese
Italian	French
Other:

Training
Yes	No	Continuing Education Course on diagnosis and treatment of special patients
Yes	No	Experience treating children with special health care needs during specialty training
Yes	No	Members of Hospital Cleft Lip/Palate Team
Yes	No	Personal experience treating patients with special health care needs

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