Dental ECHO Application

The application period for the 2023 Dental ECHO is open.

2023 Dental ECHO Application Period is Open

Please complete the application below to enroll in the 2023 Dental ECHO. Applications must be submitted by Friday, May 26, 2023. A staff member will reach out with more information after completing your application. One application should be submitted per individual provider.

Primary Contact

Name(Required)

First Last

Credentials(Required)

Title/Role(Required)

Email(Required)

Phone Number(Required)

Healthcare Site Information

Clinic/Organization Name(Required)

Clinic/Organization Parish(Required)

Clinic Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Which of the following best describes your healthcare site?(Required)

I understand that I must agree to the following:(Required)

Participant must be present at least 50% of the sessions (one session per month from May-December). Participant must be willing to submit and present at least one patient case during the calendar year, if requested. Participant must complete two surveys (pre and post survey) to assess efficacy of the program. Participants who wish to receive CEUs must also complete a brief post-session survey for each session attended.

I agree.

This field is for validation purposes and should be left unchanged.