PROJECT: DENTISTS CARE
PDC Coordinator Quarterly Report Form

Please complete the form below, tallying the numbers from all of your PDC Volunteer dentists quarterly reports (or individual tracking sheets) and enter the totals below. Reports are due on the 15th of the month following the report quarter.

Report Quarter

Component Dental Assn.

PDC Coordinator

Affiliate Dental Assn.

Email

Phone

Fax

From individual volunteer reports, please enter below
the TOTAL number of:

Volunteer Dentists

Volunteer Hygienists

Volunteer Assistants

Volunteer Hours (Dentists)

Children treated pro bono

(age 0-17)

Children treated at reduced fee

(age 0-17)

Adults treated pro bono

(age 18 and over)

Adults treated at reduced fee

(age 18 and over)

How many "no shows"

Dollar value of all dental services

Nature of dental
services provided