The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

rvdS7Wess9HW5cUIgwV5LasiQGN

Provider Enrollment Form

Thank you for your interest in becoming a participating provider for the Diamond State Smiles Club! The Diamond State Smiles Club (DSSC) is hosted by the Arkansas Oral Health Coalition and is intended to help increase the number of Arkansas children who visit a dentist at least twice a year, and help more families establish dental homes. Your participation in the Diamond State Smiles Club is voluntary, and you may choose to end participation at any time.

The information below will allow the Arkansas Oral Health Coalition to send your clinic a DSSC Provider Toolkit. Please answer each question carefully.

This project is funded by the Delta Dental of Arkansas Foundation.

Clinic name:

* must provide value

Clinic point of contact:

* must provide value

Clinic email address. This should be the email address where you will receive news and updates about the Diamond State Smiles Club.

* must provide value

Clinic shipping address. This will be where Diamond State Smiles Club provider kit materials are sent.

* must provide value

Expand

In what county is your clinic located?

* must provide value

Approximately how many children does your clinic serve each month? (Estimates are fine.)

* must provide value

Change the slider above to set a response

reset

Does your clinic accept patients with ARKids?

* must provide value

Yes

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.