Online Dentist Directory Update Form

 

We update the directory at the end of each week. Please note that this form is intended to update everything in your web listing, with the exception of your address and phone number. Address and phone number changes must be submitted to us in writing via mail or fax.

Fields noted with an asterisk (*) are required.

About you and your practice
1.
First name*     Initial  
Last name*
Office address*
City*
State*
Zip*
License number*
Office phone* ( ) -
2.
Gender
3.
Dental school #1
  Graduation year 
Dental school #2

  Graduation year 
4.

Type of practice

 
 
  Other (please explain)
5.

Do you have Internet access in your office?

     Yes    No

6.
Your e-mail address:
(If you do not wish your e-mail address to be published in the directory, please leave blank)
7.
Your web
site address:
   
Special services
8. Special services provided in your office:
(please check all that apply)
Accessible by public transit
Early morning appointments (before 9 a.m.)
Evening appointments (after 5 p.m.)
Free parking
Saturday hours
Sunday hours
Treats children
Treats disabled adults
Treats disabled children

 

 

 

 



 

Wheelchair accessibility
Your office can be listed as accessible to persons who use wheelchairs if it meets certain "functional accessibility guidelines." Please verify that your office meets each of these guidelines:

  1. Doorways and entrances to the building and office are at least 32" wide.
    Yes    No

  2. Hallways are at least 36" wide, with sufficient room for a wheelchair to make necessary turns.
    Yes    No
  3. There is enough room for a wheelchair user to travel from the waiting area to the treatment area.
    Yes    No
  4. The restroom has an accessible doorway, at least 48" of clear floor space, and grab bars to allow transfer to/from a wheelchair.
    Yes    No
  5. The building or office is accessible by more than stairs or a steep slope.
    Yes    No
  6. There are parking spaces reserved for people with disabilities.

    7. Yes    No    Parking facilities not available   

Note: Your office will be listed as wheelchair accessible only if it meets all of these accessibility guidelines.
Languages
9.

Languages other than English spoken in this office
(please select all that apply - to select multiple languages hold down the Ctrl key and click on each choice)

 
 
  Other Languages (please specify)
 
 
   
 

Attention California participating dentists

California’s SB 853* legislation requires that all health care plans provide language assistance for people with limited proficiency in English.

It is important that you let us know about your office’s language assistance capabilities. If a language other than English is spoken in your office, you need to complete, sign and submit a Language Capabilities Disclosure Form to attest to your language assistance capabilities and in which language(s).  Learn more about California's SB 853 legislation.

Download and print the form now: