Dental Staff Registration

Please complete all required fields. Fields marked with * are required.

1. Contact Information

Full Name

Mobile Phone *

Email *

Address 1

Address 2

City

State / Country

Post Code

Positions you are a candidate for *

DentistDental AssistantHygienistFront Office AssistantOrtho Assistant

NPI (Dentist only)

Years of Experience

Types of offices previously worked in

General/Cosmetic DentistryPeriodontalEndodonticOral SurgeryOrthodontic

Software trained / comfortable on

DentrixEaglesoftEasyDentOther

Are you Bilingual? *

If yes, what languages?

Days available to work

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Areas of town willing to work

NorthSouthEastWestNorthwestNortheastSouthwestSoutheast

Consent to contact (phone, text, email)? *

U.S. Citizen or approved to work? *

Ever convicted of a Felony? *

Consent to background check? *

Good standing with dental board? *

Agree to maintain state license & requirements?

Current in HIV, Blood borne pathogens & COVID? *

Annual HIPAA & OSHA updates? *

Hepatitis B vaccine? *

Dental License Number

Dental License Expiration Date

CPR Expiration Date

Date of Birth

By signing below, you are confirming that all information given is accurate.

Type your full name as your signature

Please complete all required fields to submit.

Connecting dental professionals with the practices that need them.