ADA 365 - 3M Competition

Practice Information:

Practice Name:

Number of Staff:

Names/Titles of Staff:

Address:

Phone:

Email Address:

Office Contact Person:

Type of Practice:

Private	University/School
Public Health	Other

Preventive Care:

1. What patient population(s) do you specifically target and design treatment plans for preventive care?

Young Adults	Adults	Seniors
Other (special needs, oral cancer patients, medically complex) please explain

2. What diseases/conditions do you specifically target?

Carries	Periodontal Diseases	Tooth wear
Oral Cancer	Soft Tissue Infections
Other (special needs, oral cancer patients, medically complex) please explain

3. Describe your preventive program, including: treatment measures; patient education; and risk assessment for each population. (Maximum of 250 words)

4. Describe a preventive care success story with one of the populations you target and treat in your office. (Maximum of 250 words)

5. Include any forms, patient hand-outs, or pictures from your office as examples of your office's preventive program.

Do you want to share this information with attendees of the 150th Annual Session? If not, this information will only be used in the judging of the competition.

Yes

Showcase the great preventive work being done by your team

Enter the 2011 ADA Adult Preventive Care Practice of the Year Competition

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