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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. It is our goal to be inconspicuous as much as possible, but we are a very large vehicle. Our mobile dental clinic is 38' long and has slides (bump-outs) on both sides. The minimum area that we can fit comfortably into is 50' x 20', depending upon entry and exit into parking spot. The questionnaire is designed for 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/s)?
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 park our 38' mobile dental clinic?
Is there access to a 50amp plug near parking spot (within 25ft)? See photo below for example.
Where in your building would you like us to set up our education table?
This table will have educational items for students and staff to engage in. We would also like to be present at table for about 30 minutes during the day at a peak traffic time to provide education items to passersby.
Time lunches begin and end by grade level
What is the window of time we can arrive and setup in our parking spot? (before buses arrive is ideal)
Depending on date scheduled, it may be more efficient to park the mobile unit the day before so it is already in place for the scheduled date. Would that be a possibility?
Will there be a dedicated parent volunteer or other person to run students back and forth from school to our mobile unit (strongly encouraged and appreciated)?
Address of exact visit location (good for GPS search)
Please list any information you think would be helpful to our program (best route of entry, things to watch for, special requests, etc.)
Example of 50 amp receptacle.
Lee B. Smith, MD, JD
453 Van Voorhis Road
Morgantown, WV 26505
Hours M-F 8:30-4:30
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