Dental Professional Volunteer

While all necessary supplies will be furnished, volunteer dentists are encouraged to have their chair-side assistant attend (please have them sign up separately).

Required field(s) are indicated by an *.
The fields "License Number", "License State of Issuance", "Professional Liability Carrier" and "Current Carrier Covers Volunteer Work" are only required for Licensed Dentists and Registered Dental Hygienists.
DEA Number is needed for dentist volunteers that expect to write prescriptions.
I pledge to be present for:
Radiography needs volunteers with Dexis experience.

Dentists, would you be willing to provide care for "Post Clinic Emergency Follow Up"?

I understand there is potential risk for exposure to bloodborne pathogens (BBP's) including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), as well as other bacteria, protozoa, viruses and prions during the performance of my volunteer service at this NCMOM project. I understand that I am personally responsible for any medical fees and services associated with a percutaneous piercing wound typically set by a needle point, but possibly by other sharp instruments or objects.

I understand that this is a donation of my services and that I am responsible for my own travel, accommodations, meals and medical care. I also understand that I am not entitled to reimbursement from the Dental Society or the NC Dental Health Fund for any of my expenditures.
* Date / / (MM/DD/YYYY)