SMILE Express Location Contact Form

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 *

School/location name *

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)? *

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? *

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? *

Yes No Maybe

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)? *

Yes No Maybe

Address of exact visit location (good for GPS search) *

Line 1

Line 2

City

State

Zip Code

Country

Please list any information you think would be helpful to our program (best route of entry, things to watch for, special requests, etc.) *

Submit

Example of 50 amp receptacle.