See On Calendar | Temp Fill Ins North / South

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Name

Click Dates to View on Calendar

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Phone Number

Email Address

Street Address

Job *

Hygienist
Front Office
Assistant

Upload Your Resume

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Expected Hourly Rate

Do you speak a 2nd language?

Hygiene License Expiration Date

Hygiene License Number

Are you CPR Certified? *

Yes
No

CPR Expiration Date

Upload a Picture of Your CPR Card

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Are you Nitrous Oxide Certified?

Yes
No

Upload your Nitrous Oxide Certification

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Are you Local Anesthesia Certified? *

Yes
No

Upload your Local Anesthesia Certification

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Are you Laser Certified *

Yes
No

Upload your Laser Certification

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Are you familiar with Eaglesoft Dental Practice Management Software *

Yes
No

Are you familiar with Dentrix Dental Practice Management Software *

Yes
No

Are you familiar with SoftDent Dental Practice Management Software *

Yes
No

Are you familiar with PracticeWorks Dental Practice Management Software *

Yes
No

Are you familiar using other Cloud Applications *

Yes
No

Please list the other Cloud Applications you have used

Are you Expanded Duties Skills for Dental Assistants (EDDA) Certified *

Yes
No

Upload your EDDA Certification

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Are you X-Ray Certified *

Yes
No

Upload your X-Ray Certification

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Years of Experience

Experience with Universal Sterilization *

Yes
No

Experience with Coronal Polishing *

Yes
No

Experience with Temporary Crowns *

Yes
No

Experience with Four Handed Assisting *

Yes
No

Experience with Alginate Impression *

Yes
No

Experience with Composites *

Yes
No

Experience with Cord Packing *

Yes
No

Experience with Denture Adjustments *

Yes
No

Experience with Amalgams *

Yes
No

Experience with Final Impressions *

Yes
No

Experience with Rubber Dams *

Yes
No

Upload Driver's License

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Upload Social Security Card

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Signature *

Please sign to certify your answers are true and complete