Please submit the form below. Additionally, please email us a completed Reference Verification & Release Form. PERSONAL INFORMATION Name * First Name Last Name Date * MM DD YYYY Phone * Email * Address What foreign languages do you speak? Referred by: Have you ever been charged or convicted with a felony or misdemeanor? If yes, please explain: * EMPLOYMENT DESIRED Position * RDA RDH FRONT DDS Availability * Full Time Part Time Temporary What days are you available to work? * Sunday Monday Tuesday Wednesday Thursday Friday Saturday Are you currently employed? * Yes No Available Start Date * MM DD YYYY Salary desired? * How do you feel working with children in a dental environment? * Comfortable Uncomfortable Indifferent Do you have current (check all that apply): * Hepatitis B Vaccine Radiology Certificate Nitrous Oxide Monitoring Certificate CPR Software EMPLOYMENT RECORD Please list the following: employer name, address, phone, salary paid, position, start date and end date. Employer 1 * Employer 2 * EDUCATION Please list the following for each: name, location, years attended and certificate/degree. Hygiene School * Dental Assisting School/Course * Dental School/Specialty * REFERENCES List profession, phone number and years acquainted of each reference. Please do not list family members. Reference 1 * Reference 2 * FRONT DESK ONLY Rate yourself as to ability in the areas listed below: 0 - NONE 1 - VERY LITTLE 2 - AVERAGE 3 - ABOVE AVERAGE Collections 0 1 2 3 Insurance 0 1 2 3 Electronic Filing 0 1 2 3 Appointment Scheduling 0 1 2 3 Account Receivable 0 1 2 3 Account Payable 0 1 2 3 Recall 0 1 2 3 Billing 0 1 2 3 Payroll 0 1 2 3 CHAIRSIDE ONLY Rate yourself as to ability in the areas listed below: 0 - NONE 1 - VERY LITTLE 2 - AVERAGE 3 - ABOVE AVERAGE Rubber Dam Placement 0 1 2 3 Manual X-Rays 0 1 2 3 Digital X-Rays 0 1 2 3 Panorex 0 1 2 3 Acrylic Temps 0 1 2 3 Suture Removal 0 1 2 3 Crown & Bridge 0 1 2 3 Coronal Polish 0 1 2 3 Sealants 0 1 2 3 Endo (Specialties) 0 1 2 3 General (Specialties) 0 1 2 3 Oral (Specialties) 0 1 2 3 Ortho (Specialties) 0 1 2 3 Pedo (Specialties) 0 1 2 3 Perio (Specialties) 0 1 2 3 HYGIENE ONLY Rate yourself as to ability in the areas listed below: 0 - NONE 1 - VERY LITTLE 2 - AVERAGE 3 - ABOVE AVERAGE Anti-microbial Therapy 0 1 2 3 Cavitron 0 1 2 3 Piezo 0 1 2 3 Prophy-Jet 0 1 2 3 Sealants 0 1 2 3 STM 0 1 2 3 OHI 0 1 2 3 Recall 0 1 2 3 DENTISTS ONLY Rate yourself as to ability in the areas listed below: 0 - NONE 1 - VERY LITTLE 2 - AVERAGE 3 - ABOVE AVERAGE Endo (Specialties) 0 0 1 2 3 General (Specialties) 0 1 2 3 Oral (Specialties) 0 1 2 3 Ortho (Specialties) 0 1 2 3 Pedo (Specialties) 0 1 2 3 Perio (Specialties) 0 1 2 3 Thank you for your submission! REMINDER: Please email us a completed Reference Verification & Release Form to finalize your application.
