Smile, California Community Toolkit Order Request Form

Smile, California

Community Toolkit Order Request Form

Thank you for your interest in the Smile, California Community Toolkit! Please complete the form below to request materials for your organization. These resources are designed to help promote Medi-Cal dental services and oral health education in your community. Please note that each toolkit is designed to support events or serve individuals of up to 50 people.

Date*

Organization Name*

Contact Person*

Email Address*

Phone Number*

Mailing Address*

Full address including suite number, if applicable

City*

Zip Code*

Toolkit Selection

Please select the toolkit(s) you would like to order and indicate the quantity needed of each toolkit. 1 kit supports up to 50 people.

#1 Early Childhood and Pregnancy Toolkit

Focused on materials for pregnant individuals, infants, and toddlers.

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#1 Quantity

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#1 Language

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#2 Families with Children and General Medi-Cal Dental Preventive Service Toolkit

Designed to engage parents and caregivers with children of all ages.

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#2 Quantity

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#2 Language

Select or enter value

#3 Older Adults and Family Caregivers

Includes general Medi-Cal Dental information for adults, seniors, and caregivers.

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#3 Quantity

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#3 Language

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Special Requests or Comments

Do you have any special requests or additional needs?

Acknowledgement*

By submitting this form, I acknowledge that the Smile, California toolkit materials will be used to promote Medi-Cal dental services and oral health education within my organization and community.

For questions, contact us at hello@smilecalifornia.org.

Send me a copy of my responses

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