Professional Volunteers

While all necessary supplies will be furnished, volunteer dentists are encouraged to have their chair-side assistant attend (please have them sign up separately).

I wish to volunteer for the Missions of Mercy event in Asheville, August 10-11, 2012.

* Required Field

This section is completed by licensed dentist and hygienists volunteers. Dentist volunteers that expect to write prescriptions need to provide their DEA number.


Will your current professional liability carrier cover this volunteer work?

If No, please provide a copy of your policy provisions indicating that such volunteer activities are not covered. You may be eligible for free coverage for these volunteer activities through a special program administered by the NC Dental Society and provided to you at no charge by the Medical Security Insurance Company.

Profession:









I prefer to do:



I pledge to be present for:

X-ray:



Triage:


Dentists and Assistants:




*Ending times approximate; will be based on volume of clients to be served
Dentists, would you be willing to provide care for “Post Clinic Emergency Follow Up”?

I understand there is potential risk for exposure to bloodborne pathogens (BBP's) including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), as well as other bacteria, protozoa, viruses and prions during the performance of my volunteer service at this NCMOM project. I understand that I am personally responsible for any medical fees and services associated with a percutaneous piercing wound typically set by a needle point, but possibly by other sharp instruments or objects.

I understand that this is a donation of my services and that I am responsible for my own travel, accommodations, meals and medical care. I also understand that I am not entitled to reimbursement from the Dental Society or the NC Dental Health Fund for any of my expenditures.