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TxOHC Program Sign-up Form
Full Name
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Credentials
Organization
*
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State
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Zip Code
*
Phone Number
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Email Address
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Phone Number
*
Email Address
*
Please choose one or more of the programs below to participate in.
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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):
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Individual
Health Provider(s)
Organization
Legislator/Policy Maker
Please choose any of the individual activities listed below.
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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)
Complete an
anonymous short online oral health survey
on your child.
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
Complete an
anonymous short online oral health survey
Donate pictures of individuals or with caregiver for education and learning. (
model release form
)
Please choose any of the health provider(s) activities listed below.
*
Need health experts to do topic specific presentations to be videotaped.
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 one of the presentation topics below listed below.
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Burning mouth syndrome
Mouth/Body Connection (Diabetes)
Respiratory diseases/aspiration pneumonia
osteoporosis/bisphosphonates
Association with cardiovascular disease and stroke
chronic oral and systemic conditions
Root caries
Dentures
Gingivitis/Periodontitis
Stomatitis
Xerostomia
Halitosis
Nutrition
Quality of life and psychosocial health
Clinical anxiety, depression, and other disorders
Cognitive impairment
Access and barriers to dental care for older adults
Oral health resources for older adults and their caregivers
Other
Other
Please choose any of the organization activities listed below.
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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):
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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
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