Dental Open House

For Adults with Intellectual and/or Developmental Disabilities (ID/DD)
SATURDAY November 14TH 2015
9:30-5:30 PM

Co-Sponsored by:
GRACE DENTAL OF VIRGINIA
& THE DAVID H. LAWSON FOUNDATION
Collaborative Partner: SERVICESOURCE, INC.
Funded by the Harry & Zoe Poole Foundation

Location:
GRACE DENTAL OF VIRGINIA
4530 Walney Road, #102, Chantilly, VA 20151

NOVEMBER 1st IS THE LAST DAY TO SUBMIT FORMS! FOR PATIENTS INTERESTED IN FREE DENTAL EXAMS AND FREE DENTAL X-RAYS, PLEASE FILL OUT THE FORMS BELOW.

DHLF Consent to Release of Liability Form

Medical History

Physician Authorization

Program Participant Photo Release

Registration Form

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