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Portable SMILE Express Location Contact Form
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PORTABLE SMILE EXPRESS LOCATION CONTACT FORM
Thank you for filling this form completely for each visit. We look forward to visiting your location in the near future. The questionnaire is designed for portable school-based services, so if a field does not apply, please type "N/A".
Indicates required field
What county is your location in?
Name of Principal or Administrator
Name of person filling out form
Contact person (person we will speak directly to during visit)
When will Smile Express visit your location (date)?
If visit date has not been assigned, please contact your Liaison for that information before proceeding.
Contact Person Phone Number
Contact Person Email
Time school starts and ends (ex. 7:00am - 3:05pm)
Time first bus leaves at end of day
Where would you like us to set up our portable clinic? (a 10'x15' space minumum required)
Time lunches begin and end
What is the earliest time we can arrive to begin setting up?
Is there access to power and water?
Address of exact visit location (good for GPS search)
Would someone be available to assist us in bringing in and taking out our mobile equipment?
If your location has limited cellular service, please provide Wi-Fi and password information (this will only be used for student-related business while at your school). Please list any information you think would be helpful to our program (best route of entry, things to watch for, special requests, etc.)
Lee B. Smith, MD, JD
453 Van Voorhis Road
Morgantown, WV 26505
Hours M-F 8:30-4:30
Public Health Nursing
Food Safety Training