GKAS – Procedure Tally | Minnesota Dental Association

Clinic Name*

Contact Name*

First Last

City*

County*

Phone*

Email*

Is your clinic part of a community clinic or educational organization?*

Please list how many of the following services were completed during your Give Kids a Smile event.

Exams

Prophies

Fluoride Varnishes

Fluoride Treatments

Sealants

BWX (Per Film)

Periapical Film (PAs)

PANO

Surfaces of Amalgam

Surfaces of Composite

Extractions

Stainless Steel Crowns

Pulpotomies

Root Canals

Nitrous Oxide

Silver diamine fluoride (SDF)

Oral Hygiene Instruction

Other services provided:

How many total FULL appointments did you have?*

How many available appointments did you have left?*

Total number of children seen*

Total number of dentists who volunteered at your clinic*

Total number of all volunteers (including dentists) who volunteered at your clinic*

Please list the name of each dentist (FIRST, LAST) volunteering at your event. (Note: These names will be listed in the Spring GKAS newsletter)

What is the estimated value of care you provided during your GKAS event?*

Please explain any dental health trends you saw today with your patients or concerns you have:

Please describe your overall experience with Give Kids a Smile this year. If you have any unique stories to share, we would love to hear about them.

How did most of your patients hear about the Give Kids a Smile program?

Please describe:

Were you satisfied with the number of patients your clinic scheduled? Please explain.

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Minnesota Dental Association