TxOHC Program Sign Up

Full Name *

Credentials

Organization *

City *

State *

Zip Code *

Phone Number *

Email Address *

Phone Number *

Email Address *

Please choose one or more of the programs below to participate in. *

Texas Tooth Steps

Mission 80/20

Fluoride for Texas

Texas Oral Health Summit

Will you be participating in Texas Tooth Steps as an (please choose one): *

Individual

Health Provider(s)

Organization

Legislator/Policy Maker

Please choose any of the individual activities listed below. *

I am pregnant and would like to participate in this program

Tell my friends and colleagues about this program

Provide written testimony or quote for publicity purposes

Submit a picture of my baby wearing a onesie for publicity purposes (Model Release Form required)

Please choose any of the health provider(s) activities listed below. *

Present the oral health education presentation to pregnant or new moms (approved PowerPoint presentation provided)

Recruit local WIC, Community Health Centers, pediatricians, OB-Gyns to participate

Submit a picture of a participating baby wearing a onesie for publicity purposes (Model Release Form required)

Please choose any of the organization activities listed below. *

Would like to participate in the program and dispense program materials

Provide funding to help sustain and/or expand this program

Funding to develop an oral health education video and/or program materials

Please choose any of the Legislator/Policy Maker activities listed below. *

Provide written or oral support for this program

Will you be participating in Mission 80/20 as an (please choose one): *

Individual

Health Provider(s)

Organization

Legislator/Policy Maker

Please choose any of the individual activities listed below. *

Agree to an adult Basic Screening Survey (BSS) to help provide needed data for our state

Donate pictures of individuals or with caregiver for education and learning. (Model Release Form required)

Please choose any of the health provider(s) activities listed below. *

Sign up to perform adult BSS in a facility near you

Attend calibration and standardization training to perform the adult BSS

Submit adult BSS data to ROHDEO

Encourage all non-dental health professionals to complete pertinent

education modules in the Smiles for Life national web-based oral health curriculum; medical continuing education credits provided

Please choose any of the organization activities listed below. *

Provide funding to develop an oral health education presentation(s) for RDHs and RNs to use

Provide incentives for older adults who consent and complete the screening process (e.g. Walmart $5 gift card, toothbrush, toothpaste)

Encourage medical staff to complete pertinent education modules in the Smiles for Life national web-based oral health curriculum; medical continuing education credits provided

Please choose any of the Legislator/Policy Maker activities listed below. *

Conduct a cost benefit analysis on preventive dental care for adults age 65+ and adults with disabilities (Issue Brief)

Support adult Medicaid oral health benefits to include: prophylaxis, fluoride varnish, silver diamine fluoride, scaling and root planing, extractions and dentures

Will you be participating in Fluoride for Texas as an (please choose one): *

Individual

Health Provider(s)

Organization

Legislator/Policy Maker

Please choose any of the individual activities listed below. *

Distribute one-page community CWF flyers

Sign on to a community water fluoridation support letter

Support and promote the Healthy Smiles Bill

Please choose any of the health provider(s) activities listed below. *

Volunteer to be community CWF spokesperson

Hang CWF posters in waiting or exam rooms

Discuss fluoridation with patients

Volunteer to engage community policymakers

Sign on to a community water fluoridation support letter

Support and promote the Healthy Smiles Bill

Please choose any of the organization activities listed below. *

Sign on to a community water fluoridation support letter

Support and promote the Healthy Smiles Bill

Please choose any of the Legislator/Policy Maker activities listed below. *

Author or sponsor Healthy Smiles Bill to promote transparency and democracy within local communities

Local policymakers support CWF for your community

Will you be participating in the Texas Oral health Summit as an (please choose one): *

Individual

Health Provider(s)

Organization

Legislator/Policy Maker

Please choose any of the individual activities listed below. *

Attend the Oral Health Summit for your own edification

Learn more about oral health to share with friends and family

Improve you and your family’s oral health

Choose a TxOHC program to participate in at your community level

Please choose any of the health provider(s) activities listed below. *

Attend the Summit and earn dental CEU’s

Invite a colleague(s) to the Summit

Broaden your network and interact with colleagues from around the state

Choose a TxOHC program to participate in

Present a poster

Volunteer to be a speaker

Please choose any of the organization activities listed below. *

Help sponsor the Summit

Sponsor a speaker

Sponsor an event

Give in-kind donations for summit supplies

Sponsor a student(s) to attend the Summit

Take advantage of group rates on registration

Please choose any of the Legislator/Policy Maker activities listed below *

Agree to be the Keynote speaker

Participate in state oral health forum