Registration: DentalProTemps LLC Shiftboard

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APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Birthdate
SSN
Drivers License Number
Dental Experience
1-5 years
6-12 years
13-20 years
over 20 years
Please select any specialty field experience you have
Oral Surgery
Ortho
Perio
Pedo
Multi-lingual Languages
Spanish
Other
Do you have current (check all that apply)
Hep B Vaccine
CPR
N20 Certification
OSHA / Bloodborne Pathogen
Have you been convicted of a felony?
 Yes  No
Referred by:
DEA # Expiration Date
Malpractice Insurance Expiration Date
Dental Renewal License Expiration Date
CPR Certification Expiration Date
Policies and Procedures Expiration Date
NC Dental License Number

Availability
Hourly Wage Desired ($)
Are you currently employed?
 Yes  No
Date you can start
Alright to contact at work?
 Yes
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?

Experience
Dentistry Skills - Please indicate your level of skill for each section 0-None, 1- Very Little, 2- Average, 3- Above Average
Simple Extraction
Composite Filling
One Surface - CF
Two or Three Surfaces - CF
Class 5 - CF
Amalgam Filling
One Surface -AF
Two or Three Surfaces - AF
Class 5 - AF
Crowns
Bridges
Core Build Ups
Impression Accuracy
Porcelain Veneers
Direct Veneers
Onlays
Inlays
Occlusal Adjustments
Rapport with Children
Rapport with Adults
Local Anesthesia Administration
Nitrous Oxide Sedation
Invisalign
Periodotal Therapy
Placement of Antimicrobials
Open Flap Debridement
Gingival Grafts
Scaling and Root Planing
Periodontal Stabilization Splints
Crown Lengthing
Endodontic Therapy
Root Canal Therapy Anterior Teeth
Root Canal Therapy Molars
Pulpotomy
Apicoectomy
Oral and Maxillofacial Procedures
Dental Implants
Surgical Tooth Extractions
TMJ Treatments (i.e. Night Guards, Equillibration, Occlusal Guards)

School/Professional References
College/University Name
College/University Graduation/Certificate Award Year
Dental School Name
Dental School Years Attended and Certification/Degree
Advanced Specialty School Name
Advanced Specialty School Graduation/Certificate Award Year
Professional References (No Friends or Family)
First Reference Name
First Reference Position
First Reference Phone
Second Reference Name
Second Reference Position
Second Reference Phone

Work Experience
Experience (1) Company Name
Experience (1) Position/Title
Experience (1) Supervisor
Experience (1) Address
Experience (1) End Date
Experience (1) Start Date
Experience (2) Company Name
Experience (2) Position/Title
Experience (2) Supervisor
Experience (2) Address
Experience (2) Start Date
Experience (2) End Date

Emergency Contact Information
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Address
Emergency Contact (2)
Emergency Contact Relationship (2)
Emergency Contact Phone (2)
Emergency Contact Address (2)
Physician Name
Physician Phone
Insurance
Medications



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