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Please print, fill out email, mail or fax to Daily Dental Solutions, inc.
Name: Title:
Maiden Name or Alias: Phone:
Email: Alternate Phone:
Address:
Date of Birth: Date available to start:
Have you ever worked for or interviewed with DDS, inc.? If so when?
Days you are available: __ Mon __ Tues __ Wed __ Thurs __ Fri __ Sat
Areas you can work in: __ N OKC __ Edmond __ Guthrie __ S OKC __ Del City
__ Midwest City __ Mustang __Moore __ Norman __ Yukon __ ElReno __Shawnee
__ Chickasha __Newcastle/Tuttle __ Purcell __ Pauls Valley __ Stillwater __ Tulsa
__Woodward ___Enid __Ada __Duncan __Altus __Lawton ___Weatherford __Clinton
Any Other Areas: _______________________________________________________________
______________________________________________________________________________
What distance are you willing to drive one way?
How much notice do you need? Are you interested in last minute jobs?
What is the earliest we can call? (We open at 6 am & make calls at 6 for last min jobs) ____
What is the latest you can be called? (We generally will not call after 10 pm) _____
Are you bilingual? If so what languages? ____________________________________________
How many years of experience do you have in the dental field for this area of expertise? ______ How many years of dental experience in a different area? ________ Please list the types
of practices you have worked in? __________________________________________________
______________________________________________________________________________
Front Office Support: Please specify all procedures you are comfortable in performing....
__ Scheduling __ Insurance File/Process __ Accounts Payable/Receivable __ Billing
__ Financial Arrangements __ Recall System __ Case Presentation
___ Medicaide/SoonerCare ___ Hygiene Coordinator ____ Office Management
Dentists, Registered Dental Hygienists and Dental Assistants you will need to provide us
a copy of your license/certificate. You will need to keep a copy with you at all times when
working as a temporary for Daily Dental Solutions, inc.
Do you have any expanded functions?
Dentist: _ ______ NPI _______ OK Board of Dentistry Lic ______ Controlled Substance
______ Dispensing Dentist ________ OK Bureau of Narcotics _____________ SoonerCare
_________________________________________________ Malpractice Policy & Expiration
RDH: ___ Local Anesthesia ___ Nitrous Oxide ____ CPR
DA: ___ CDA ___ Radiation Safety(x-ray) ___ Coronal Polishing ___ Sealants
___ Nitrous ____ Permit # with OK Board of Dentistry (required) ____ CPR
Are you experienced with any of the following? __ Intraoral Camera __ Digital x-rays
____ Nomad ____ Invisalign _____ Implants ____ Cerac ___ Computerized Charting
____ Fabricate Temporary Crowns ____ Rubber Dam Placement ___ Periodontal Charting
____ Endodontic Rotary System ____ Endodontic Oscillating System
List any dental software(s) used: ___________________________________________________
List any experience in Dental Specialty Practices: _____________________________________
Are there any dental procedures you are not comfortable performing?______________________
______________________________________________________________________________
If needed are you willing to help in other areas (if not busy)? ____________________________
Has your license/certifications ever been revoked for any reason? _____ If so Why? _________
Have you ever been disciplined in any state by any Board of Dentistry? ___________________
Have you ever been involved in a malpractice lawsuit? ______ If so Why? _________________
List 3 professional references (not family or former employers). You can use friends, coworkers, people you have volunteered with, etc. Please list name phone numbers & email (if possible).
- ________________________________________________________________________
- ________________________________________________________________________
- ________________________________________________________________________
Present & Previous Employment History (also include any temp work)
If applicable, may we contact your current employer? _______ (We will contact all previous employers to verify work history.)
#1 Employer Name ________________________________ City & State _______________
Phone # __________________________ Position Held _____________________________
Date of Hire ________________________ Last Day of Employment ____________________
Reason for leaving/termination __________________________________________________
#2 Employer Name _______________________________ City & State ________________
Phone # _________________________ Position Held _______________________________
Date of Hire ______________________ Last Day of Employment ______________________
Reason For Leaving/Termination _________________________________________________
#3 Employer Name ______________________________ City & State __________________
Phone # ________________________ Position Held ________________________________
Date of Hire _______________________ Last Day of Employment _____________________
Reason for Leaving/Termination _________________________________________________
IF not already listed, please provide a list of ALL dentists/dental offices employed by or temped for: _______________________________________________________________________
__________________________________________________________________________
Education:
College/University __________________________________________ State ____________
Dates Attended _____________________ Degree/Diploma/Certificate __________________
Are there any dental offices you will not work in & reason why: ________________________
____________________________________________________________________________
Please provide concise information regarding your skill & experience level. Include the type of
temporary work you are looking for (ex. Dentist, Dental Hygienist, Assistant, Front Office
Support, etc.) ________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do you smoke? ________ Are you comfortable working with children?_________________
We do background checks on all applicants. Will you pass a background check? ____ Please list any misdemeanor or felony charges that may show up on your record. _____________________________________________________________________________
I have completed this truthfully and to the best of my knowledge.
_____________________________________________________________________________
Print Name & Title
_____________________________________________________________________________
Signature Date
Last updated 12/20/2018
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