Dental Assistant Registration

Please fill out the following application for Dental Assistant positions.


* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Birthdate
SSN
Drivers License Number
Please select any specialty field experience you have
Oral Surgery
Ortho
Perio
Pedo
Dental Experience
Office Trained
Dental Assisting School Graduate
1-5 years
6-12 years
13-20 years
over 20 years
Prefered Employment Status
Are you currently employed?
 Yes  No
Alright to contact at work?
 Yes
Date you can start
How do you feel about working with children?
Hourly Wage Desired ($)
Maximum Travel Distance (miles)
Is there any circumstance in your past employment that might negatively influence future contracting positions/contracting dental offices?
Permanent Position Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Temporary Position Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Multi-lingual Languages
Spanish
Other
Do you have current (check all that apply)
Hep B Vaccine
CPR
N20 Certification
DA's Radiology Certification
OSHA / Bloodborne Pathogen
Coronal Polish Certification
Please list offices in NC to which you do not wish to return:
Physician Name
Physician Phone
Insurance
Medications
Referred by:
Have you been convicted of a felony?
 Yes  No

References
First Reference Name
First Reference Position
First Reference Phone
Second Reference Name
Second Reference Position
Second Reference Phone

Education
College/University Name
College/University Graduation/Certificate Award Year
Hygiene School Name
Hygiene School Graduation/Certificate Award Year
Dental Assisting School/Course Name
Dental Assisting School/Course Years Attended and Certification/Degree

Emergency Contact Information
Emergency Contact
Emergency Contact Phone
Emergency Contact Relationship
Emergency Contact Address
Emergency Contact (2)
Emergency Contact Phone (2)
Emergency Contact Relationship (2)
Emergency Contact Address (2)

Skills
Model Pouring
Endodontics
Bands & Brackets
Four-Handed
Periodontics
Orthodontics
Sterilization Techniques
Wax Bites
Oral Surgery
Alginate Impressions
Model Trimming
Crown & Bridge
Implants
Pit & Fissure Sealants
Cerec
Dental Rubber Dam
Charting - Paperless
Acrylic Temp Crown Fab.
Tray Set-Ups
Panoramic X-Rays Digital
Type
Scan X
Sensors
Suture Removal
Office Equip. Maintenance
Dental Software
Please list any Dental Software used



Thank you for your interest!
 
 
Greensboro, North Carolina 27407
336-307-3631
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