Hygienist Application

Please fill out the following form for Hygienist positions.


* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Please select any specialty field experience you have
Oral Surgery
Ortho
Perio
Pedo
Birthdate
Drivers License Number
SSN
Have you been convicted of a felony?
 Yes  No
Referred by:
Dental Experience
Dental Hygiene School Graduate
1-5 years
6-12 years
13-20 years
over 20 years
Do you have current (check all that apply)
Hep B Vaccine
CPR
N20 Certification
OSHA / Bloodborne Pathogen
Multi-lingual Languages
Spanish
Other
Are you currently employed?
 Yes  No
Alright to contact at work?
 Yes
Date you can start
Hourly Wage Desired ($)
Maximum Travel Distance (miles)
Prefered Employment Status
Permanent Position Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Temporary Position Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How do you feel about working with children?
Is there any circumstance in your past employment that might negatively influence future contracting positions/contracting dental offices?
Physician Name
Physician Phone
Insurance
Medications

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

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
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
Placement of temporary fillings
Oral Hygiene Instructions
Anti-Microbial Therapy
Scale and Root Plane
Recall system
Digital X-Rays
Type
Scan X
Sensors
Dental Software
Please list any Dental Software used
Pit & Fissure Sealants
Cavitron
Local anesthetic (if applicable)
Charting
Soft Tissue Management
Hand Scaling
Invisalign
Ultrasonic Scalers (Piezo, etc)
Probing
Prophy Jet



Thank you for your interest!
 
 
Jamestown, North Carolina 27282
336-307-3631
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