Take 5 Form

Inspired by the Colorado Dental Association’s Take 5 Program and directed by the 2016 House of Delegates, the Washington State Dental Association is encouraging our private practice members to accept 5 Medicaid patients on the honor system and at their discretion, to increase access to quality oral healthcare for our state’s most vulnerable populations.

Please join your colleagues in this effort and pledge your commitment to “Take 5” by filling out this form. Thanks for all you do!

I will join my colleagues across Washington to help care for the underserved in our state by seeing at least 5 Medicaid patients/families in my practice:

Per Week
Per Month
Per Year
Other

I will treat the following types of Medicaid patients (check all that apply):

First Choice
Second Choice
Third Choice
Children
Adults
Elderly
Physically or Developmentally Disabled

Please provide the following basic contact information.
Please note that this information is for internal WSDA purposes only and will not be made public.

First Name

Last Name

Email Address

Practice Name

Practice Address

Additional Participating Practice Addresses (If Applicable)

WSDA may publish the names of participating members in future editions of the WSDA News. If you would like your name to potentially appear in future publications, please check the box below.

If you would like your name to potentially appear in future publications, please check this box:

Yes, I give the WSDA permission to potentially publish my name in future publications.

Sign Up to "Take 5"

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