Temp Dentist Application Page

Timestamp

Your Name *

Street Address 1 *

City *

State *

Zip Code *

Email Address *

Best Phone Number For Contact *

Social Security Number *

DEA Number *

DEA Expiration Date *

Dental license number/State *

Date of expiration of dental license *

Other Dental license numbers/State *

Date of expiration of other Dental license *

Malpractice insurance company *

Malpractice policy number *

Amount of malpractice coverage *

Date of expiration of malpractice insurance policy *

What days are you available to work? *

(Check all that apply.)

The farthest you will travel for a job: *

(in miles)

Specialty experience?

Do you have Licensure and Malpractice Coverage for Nitrous Oxide? *

(Select Yes or No)

Dental Procedures You are Comfortable Performing: *

(Check any that apply)

Endo Experience

(Check any that apply.)

Computer System Experience

(Check any that apply.)

If you have completed a residency program, what type, where, and when?

Have you received the Hepatitis B vaccine series?

(Select Yes or No)

If you have any additional information, qualifications, or questions about Dr. Fill-In that you would like to include, please do so below:

Please list below the name, phone number, and address of your first dental reference: *

Please list below the name, phone number, and address of your second dental reference: *

Please list below the name, phone number, and address of your third dental reference: *

Dr. Fill-In Subcontractor Application Form