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Dr. Fill-In Subcontractor Application Form
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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?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
(Check all that apply.)
The farthest you will travel for a job:
*
(in miles)
Specialty experience?
General
Pedodontics
Orthodontics
Periodontics
Endodontics
Oral Surgery
Other
Do you have Licensure and Malpractice Coverage for Nitrous Oxide?
*
Yes
No
CHOOSE
(Select Yes or No)
Dental Procedures You are Comfortable Performing:
*
Amalgams
Composites
Cosmetic Bonding
Crown and Bridge
Restoring Implants
Placing Implants
Porcelain Veneers
Removable Prosthetics
Endodontics
Emergencies
Hygiene Checks
Diagnosis
(Check any that apply)
Endo Experience
Molar
Bicuspids
Anterior
Conventional
Rotary
None
(Check any that apply.)
Computer System Experience
Softdent
Dentrix
Eaglesoft
Other
(Check any that apply.)
If you have completed a residency program, what type, where, and when?
Have you received the Hepatitis B vaccine series?
Yes
No
CHOOSE
(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:
*
Website
Submit
Temp Dentist Application Page
July 16th, 2020
faystricklin
Call
(610) 216-2899
and start the conversation!
Let's get to work solving your dental service or employment needs!