Dentists Volunteer Here

Registration Form

Personal Details
Name:
Practice Name:
Dental Provider No.:
Participating Dentist:
Email:
Phone:
Practice Site 1
Street:
Suburb:
Town/City:
State:
Postcode:
Practice Site 2
Street:
Suburb:
Town/City:
State:
Postcode:

Availability:
During what time period/s are you able to donate your services?

	August '08		September '08		October '08
	November '08		December '08

If these months are not suitable please call our coordinator on 9818 0915 or email info@brightsmiles.net.au.

Available hours:

Monday:	8am - 5pm	Other:
Tuesday:	8am - 5pm	Other:
Wednesday:	8am - 5pm	Other:
Thursday:	8am - 5pm	Other:
Friday:	8am - 5pm	Other:

Number of children you are prepared to treat:

Clinical treatment you are prepared to provide:

Oral Hygiene	Clean & Polish	Examination (Treatment Plan)
Simple restorations	Complex restorations	Extractions
Sedation	Pulp Therapy	Stainless Steel Crowns
Mouthguards	X-rays	Orthodontics
Other

* Please note that in order to qualify you must offer a minimum service of examination and treatment plan.

Recruitment of Children

Do you have any existing relationships with other organisations or programs providing probono dental care?

	Yes - Please specify who:
	No

Media and Promotions

Are you willing to be publicly acknowledged as a volunteer dentist participant in Bright Smiles?

	Yes
	No

Are you prepared to be interviewed and quoted / photographed / filmed in media activities promoting Bright Smiles to motivate other dentists to sign up?

	Yes
	No

Have you provided pro bono treatment to children in need in the past which may provide the basis for a media story?

	Yes
	No

Other

Are there any special conditions on your participation?

	Yes - Please specify:
	No

Do you have any other comments or questions?

I confirm that I have indemnity insurance which will cover treatment of children referred to me in the Bright Smiles programme

	Yes
	No

I wish to receive updates on the Bright Smiles initiative.

I wish to receive information about other community oral health initiatives.

Thank you for your interest in supporting Bright Smiles. Our coordinator will be in touch.

Sydney dentist Nick Hocking kicked off Bright Smiles by treating Jerson and Caleb Hidalgo

To help kids in need, we need hundreds of dentists from across Australia to volunteer their time. The level of commitment is up to the practitioner. Please consider getting involved, and give a kid a smile! Click here to find out how your dental surgery can get involved.

A community volunteer initiative supported by Colgate.