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DOCTOR CANDIDATE PROFILE
Doctor Candidates
Basic Information
Salary
Experience
Basic Information
First Name
Last Name
Mobile Phone
Email Address
What is your area of speciality?
General Dentist
Pediatric
Orthodontist
Oral Surgeon
General dentist practicing pediatric
Candidate is looking for
Full-time
Part-time
Locum Tenens
How many days / week do you wish to work?
Average monthly production numbers (if applicable)
List the procedures in order of proficiency
List the lab(s) that you work with
Interview Date
Where do you currently reside?
Are you willing to relocate?
Yes
No
If yes, please list the city and states in priority order
Previous
Next
Salary
Daily Rate Guarantee, Amount?
% of Production
% of Collections
What benefits are important to you?
Medical
Dental
Vision
Malpractice
CE
Previous
Next
Experience
In which states / countries are you currently licensed to practice?
Do you have any past or pending disciplinary actions or license suspension?
Yes
No
If yes, please explain the situation and the outcome
Do you currently work in a Private Practice or DSO?
Private Practice
DSO
Do you have hospital credentials?
Yes
No
If yes, where are the credentials for?
What is your current contractual obligation to give notice or resign?
If you are still in dental school / residency, when is your expected graduation date?
Have you completed an internship / externship?
Yes
No
If yes, where was the internship / externship?
What board exams have you successfully completed?
Do you have any other certifications / qualifications that you would like us to be aware of?
What practice management software(s) have you been trained to use?
Dentrix
Eaglesoft
Softdent
Open Dental
Other
What system(s) are you experienced in?
CAD CAM
Digital X-Rays
Invisalign or Clear Aligner Certified
Implant Placement
Other
Additional details about the systems above that would be helpful to know?
Do you require an employee sponsorship for H1B or Visa?
Yes
No
If you currently have an H1B or Visa, when does it expire?
What languages do you read / write fluently?
Do you have friends or peers who are looking for associate positions that you can recommend for us?
Name / Title of who completed this form
First Name
Last Name
Title
CV Upload
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