Organization Details
Name*

Organization*

Dentist / RDH

The above dentist is attending this mission
Dental Office Details
Address Line 1*

Address Line 2

Suite #

City*

State*
PunjabSindhKPKBalochistanAJ&K
Postal Code*
Phone*

Email*
You will be contacted via (email, telephone, etc.) once the request has shipped.
Brief Summary of Organization/Mission*

Humanitarian Mission Details
Target Population

Location of Mission *

Number of Volunteers *
Dentists

Dental Assts

Others

Estimated number of patients served weekly OR during humanitarian Camp*

Treatment Procedure Performed *

Products Needed
(Please note that the requested products are NOT a guarantee on what will be sent.) *

Terms and Conditions
I consent to allow Canva Dental to use the provided information to contact me regarding and to evaluate my request. If this request is approved, as consideration for receipt of Canva Dental product(s) donated for humanitarian purposes I certify that:(i) donated products will not be sold or transferred to anyone for any purpose not consistent with the statements made in this request form: (ii) all dental services required in connection with use of donated products shall be provided to the patient(s) free of charge: (iii) donated products will be used in accordance with their labeled instructions and (iv) I agree to hold harmless Canva Dental, The Diversity Foundation and affiliates from any and all liability for use of the donated product(s).
By checking the box you agree to the terms and conditions above *