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DentalStaffers.com - Serving the Employment Needs of the Dental Profession Exclusively


Please tell us something about yourself using the form below. All information will be kept strictly confidential.

First Name:	(Required)

Last Name:

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Email:

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Address:

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City:

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State:

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Zip:

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Phone #:

Pager/Cell:

Additional Phone #:

Date of Birth:


Education Completed: (Required)

Years of Experience:

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What days are you available?

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Are you willing to travel?

Yes

What counties?

Have you had any experience in the following specialty fields?
Perio		Endo		Oral Surgery		Pedo		Ortho		Prostho

Are you interested in a Permanent Position?

Yes No

Are you interested in a Temporary Position?

Yes No

I am a:	Chairside Assistant	Registered/Certified Dental Assist.
	Dental Receptionist	Office Manager
	Consultant	Registered Dental Hygienist
	Dentist	Specialty

State or Nat'l Certification:

X-Ray License:

Please tell us your
hourly rate:

Do you:

Take X-Rays	Develop X-Rays	Mount X-Rays
Four-handed Chairside	Mix Alginate	Make Trays/Temps
OSHA Prescribe Sterilization		& Disinfection
Operate Autoclave	Operate Dry-Clave	Ultrasonic
Post Operative Instructions		Oral Hygiene Instruction
Soft Tissue Management		Know how to chart
Perio Chart	Operate a Computer	Computer System
Schedule Appointments		Fill out insurance forms

Please tell us who referred you to DentalStaffers.com

References (Required)
Please list two references that can be checked by this agency:

1.	Name:
	Address:
	Phone:
2.	Name:
	Address:
	Phone:

Employment History (Required)

From (Date):

To (Date):

Employer:

Address:

Position Held:

Reason for Leaving:

Responsibilities:

From (Date):

To (Date):

Employer:

Address:

Position Held:

Reason for Leaving:

Responsibilities:

Additional Information:

Bilingual:

Additional work experience or training that you think we should know about?

Healthcare Auxiliary Informed Consent Statement
Release of Information, IRS & Waqes Information, Hepatitis B Vaccine Information

I the undersigned healthcare professional, acknowledge that you may receive requests from doctor's offices for information pertaining to my past employment in the form of a work history or a resume. I do authorize STAFFERS to release such information to any doctors or healthcare offices/facilities that may request such information.

I also understand that I have chosen to work as a healthcare auxiliary through STAFFERS and that as a representative of the agency I will utilize my healthcare skills and knowledge with the utmost professionalism. I will not allow myself to be directly solicited (offices calling you directly at home) for temporary or permanent work by any office or healthcare facility where STAFFERS has made the initial introduction or placement of a temporary assignment, or interview for permanent employment. If I am asked to return to an office or healthcare facility where STAFFERS has made the initial introduction, and I do accept additional temping days or a permanent position, I understand that it is MY RESPONSIBILITY to inform STAFFERS. If I choose not to inform STAFFERS, I am aware that I am liable to STAFFERS for the applicable fees incurred. (Temping fees / Permanent Placement fees)

It is our responsibility to inform you that if taxes are not withheld from your earnings, while on assignment, from the doctor or healthcare facility with whom you were working, that you are responsible for keeping accurate records, and reporting your wages for year end filing of income taxes. (If you are not sure what expenses are tax deductible, please call our office for an expense sheet and we will mail it to you). If an office requests that you sign a release or a temporary personnel agreement, this is acceptable. It just states that you will not hold the office responsible for contributing to your unemployment taxes, disability benefits or workman’s' compensation. It also states that you will not be eligible for any of that offices' medical or pension benefits package. (which the regular permanent staff members may be entitled to) As a healthcare professional / independent consultant, we suggest that you have introduction cards printed (or print them yourself on your computer) and leave them with the office manager at the office or healthcare facility where you may be assigned.

By clicking Submit I acknowledge that I do agree to this binding contract.

HEPATITIS B VACCINE / TB / PPD TEST

The Hepatitis B Vaccine is strongly recommended to all clinical auxiliaries in the medical and dental professions. It is not a requirement (for certain personnel) yet, but if you are considered clinical healthcare personnel and the possibility of exposure to blood and body fluids is part of your clinical work environment, it is a preventative option to be considered if you haven't already had the series.

Please check the appropriate statement. If you have proof of negative tests, you may be asked to submit same prior to employment.

I have not been given the Hepatitis B Vaccine Series of injections.
I have been given the Hepatitis B Vaccine Series of injections.
I have proof of negative TB Test.
I have proof of negative PPD Test.

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