Dental Associate Order
Company Information
Dentist/Practice Name
Contact Name (if different from practice)
Address
City
State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
Main Phone
Fax
E-mail address
Practice Information
Type of practice General Endodontics Oral Surgery Orthodontics Pedodontics Periodontics Prosthodontics
How Many: RDH's DA's Operatories
Average Number of Patients Daily
Fee for service % Capitation % Medicaid %
Number of Active Patients
Have you used our service before? Yes No Not Sure -Choose-
Order Information
Standard Hire Temp to Hire
Description of Ideal Candidate
Specific Skills Needed
Frequent Procedures
Years Experience
Will you accept a new grad (check if yes)?
Is there buy in or buy out potential? -Choose- Buy In Buy Out No
Factors that would rule out a candidate
Compensation Base
Bonus
Production
Benefits
Any Other Special Instructions?
If you have a written job description please paste here
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