RAM LA
RAM LA Medical Professional

Register As A Dental Professional

Thank you for your interest in volunteering your services for this great event. Your generosity is what helps make everything we do possible. To apply fill out the following information. After you submit your registration you will go through an approval process that could take up to 7 days. At the end of this process we will notify you of your registration status along with any other information pertaining to the event you register for. Again, thank you and we hope to see you at the event.

Step 1: Select A Date

Please select the day you would like to volunteer for.

Please note: To register for more than one event date you will need to complete the registration process for each date you wish to apply for.

Volunteers may not receive healthcare services

Licensed dental professionals may receive 4 hours CE at no charge. Course materials will be available each day.

Step 2: Choose Shift

Choose the time of the day that you would like to volunteer.

Step 3: Fill In your Information

Please fill in your information.

Please note: If you are a 4th year student, please mark the license field as none or NA

First Name*
Last Name*
Address*
State*
Zip*
Phone*
Email*
License #*
Comments

Step 4: Select Your Profession/Specialty

Dental AssistantDental StudentEndodontistGeneral DentistHygenist
Oral SurgeonPediatric DentistPeriodontist

Step 5: Read The Agreement

I hereby attest that my license/certificate is not restricted, suspended or revoked nor is any such action pending, pursuant to disciplinary proceedings in any jurisdiction.

Confidentiality:
I agree that while I am participating as a registered volunteer at the Remote Area Medical Clinic, I will maintain the strict privacy and confidentiality of all patients. This includes all present and future communications, digital, written and verbal, referring to any Remote Area Medical patient. I agree that unless I am obtaining medical information necessary for patient care, I WILL NOT ASK a patient for any personal information, including questions regarding medical insurance coverage, Medicaid, or Medicare. I agree not to photograph or otherwise record patients while at a Remote Area Medical event.

Release and Indemnification:
I release and indemnify Remote Area Medical, a non-profit organization, and all its respective officers, directors, agents, contractors, volunteers, heirs, successors and assigns, from prosecution or presentation of any claim for bodily injury or death or for property loss or damage incurred in connection with the Remote Area Medical clinic indicated above or related activities. I fully understand that I am volunteering at my own risk and that due to my occupational/other possible exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection or other bloodborne pathogens. I understand that if it do not have the HBV vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I want to be vaccinated with Hepatitis B vaccine, I can do so at my own expense.

I have read, understand and agree to all of the terms stated above
Initial*