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Client Registration: MDC Staffing LLC, Shiftboard

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APPLICANT INFORMATION
 
ADDITIONAL INFORMATION
Preference: Male or Female
Company Name
Does your office use film x rays?
 Yes  No
Does your office use digital X rays?
 Yes  No
What type of Digital X rays does your office use?
Does your office use Cerec?
 Yes  No
Does your office use iTero?
 Yes  No
What is your payroll Protocol?
Is your office paperless?
 Yes  No
Is your office:
General
 Yes  No
Pedo
 Yes  No
Perio
 Yes  No
Ortho
 Yes  No
Endo
 Yes  No
Oral Surgery
 Yes  No
Prostho
 Yes  No
Other:
What software does your office use?
Temp will be paid
TEMP WILL BE PAID BY
If other, please explain.
Does your office do Assisted or accelerated hygiene appointment?
 Yes  No
Please explain as needed
Additional Notes or special requests
Does your office accept:
DHMO
 Yes  No
PPO
 Yes  No
Medicaid
 Yes  No
Chips
 Yes  No
Medicare
 Yes  No
Other
 Yes  No
Notes
Time Alloted for Hygiene Appointments:
Adult Recare
New Patient
Perio
Pedo
Ortho
Does you office do ortho?
 Yes  No
Traditional
 Yes  No
Invisalign
 Yes  No
Other
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Cypress, Texas 77429
713-953-9500

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