Organization Profile Form

Registered Dental Assistant (RDA) AMT & Dental Assisting Radiography (DAR) AMT
Please note: Programs must be active and currently enrolling, instructing, or graduating students at the time organizational profile information is submitted for AMT review. AMT is unable to review or approve inactive, discontinued, or planned programs that are not yet operational.
Organization Profile
Organization Name
Campus Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Type
High School Affiliate
Name of Partnered Organization
Accreditor (check all that apply)

Other
Current certification agency used (check all that apply)

Other
Professional Website Address and/or Academic Program Links
example: www.amt-university.org
Contact Info
Contact Name

First NameLast Name
Title
Business Email
example@example.com
Phone Number
Format: (000) 000-0000.
Program Curriculum

As indicated in your organization's course catalog
Number of Classroom Clock Hours
(Convert credit hours to clock hours)
Number of Externship Clock Hours
(Convert credit hours to clock hours)
Length of Program
(Length of time it takes for students to complete the program)
Attach a copy of your syllabus or course outline

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Does your program include the following content areas?
Office Assisting Skills
Clinical Procedures
Dental Sciences
Dental Radiography /Radiology
Minimum Program Requirements

Check all areas below which apply to your curriculum
OFFICE ASSISTING SKILLS
Office Procedures
Patient Management and Communication
Ethics and Professional Conduct
Office Assisting Skills Selected
DENTAL SCIENCES
Dental Anatomy and Terminology
Patient Education
Local Anesthesia
Medical Emergencies
Infection Control
Dental Materials
Dental Science Selected
CLINICAL PROCEDURES
Instruments and Equipment
Chairside Procedures
Dental Specialties (Endodontics, Periodontics, Orthodontics, Pediatric, Prosthodontics, Oral and Maxillofacial Surgery)
Laboratory
Clinical Procedures Selected
DENTAL IMAGING

Radiology
Principles and Theory
Techniques and Application
Radiograph Film Processing and Mounting
Safety
Dental Imaging Selected
Total Program Requirements Selected
Decimal of Program Requirements Selected
% of Program Requirements Selected
By submitting this form, I am attesting to the accuracy of the information provided.
Agreement
Please verify that you are human
N/A - Accreditor
(If other)
N/A -Current certification agency used
(if other)
Account Care
Should be Empty:

Registered Dental Assistant (RDA) AMT & Dental Assisting Radiography (DAR) AMT

Organization Profile

Contact Info

Program Curriculum

Does your program include the following content areas?

Minimum Program Requirements

OFFICE ASSISTING SKILLS

DENTAL SCIENCES

CLINICAL PROCEDURES

DENTAL IMAGING