Thank you for taking the time to thoroughly complete the Practice Profile Form. The more detailed information that you provide, the more successful we will be in searching for the ideal candidate(s).

If you have multiple locations that you are hiring for, we require a separate Practice Profile Form for each location. 

Practice Company Information
Name on dental practice sign at physical address where associate will be working : Name on dental practice*  
Dentist Owner Name:    Dentist Owner Name*

Office Phone Number: Office Phone Number*   Website:   Website*   Would the new associate be the only dentist working in the practice?   Yes   No*            

Hiring Manager Direct Contact Person
Name/Title:   Name/Title*  Office Number:      Office Number*   Mobile Number:      Mobile Number* May we text you?   Yes   No*    
Email Address:   Email Address*        

Practice Background 

Number of dentists working in hiring practice:   Number of dentists working in hiring practice*  GP   GP*   Specialty   Specialty*   
If specialties, please list:

Number of hygienists at hiring location:   Number of hygienists at hiring location*Number of daily hygiene exams assigned to associate:   Number of daily hygiene exams assigned to associate*   Will the associate have autonomy in materials/lab use?    Yes   No*  Mix of Patients:    % FFS*   % FFS   % PPO*   % PPO   % DMO*   % DMO   % Medicaid*   % Medicaid
Practice Management Software:   Practice Management Software:*   CAD CAM:   CAD CAM: *   Digital X-Ray System:   Digital X-Ray System:*   Implant System:   Implant System:* Endo system:   Endo system:*   Pano   CBCT*  
Digital Scanner*    Intra-oral Camera*      

Position/Details

Why are you seeking a candidate(s)?   Replace   Expansion*         Is this search confidential?   Yes   No* 
Is this search confidential?   Is this search confidential?*    
Who are you hiring:  
GP   Specialty   Pedo   GP Practicing Pedo   Ortho   Endo   OMS*      Minimum years of contract?   Minimum years of contract? *   Non-compete?   Yes   No*   
Distance and duration of non[compete?

Daily Guarantee, Amount?*Daily Guarantee, Amount?*       How long?   How long?*   % of Production, What is the %?*% of Production, What is the %?*    Is it tiered?   Yes   No*        % of Collections, What is the %?* % of Collections, What is the %? *  Is it tiered? Yes   No* Will associate be paid as: W2   1099*              

Is there Partnership/Ownership/Equity Opportunity?    Yes   No*               
Uniforms supplied? Yes   No*            
Specific Position Requirements: 

Years of experience required:   Years of experience required:* Is a new grad acceptable?   Yes   No*   
Are you willing to sponsor candidates needing H1B or Visa assistance?   Yes   No*       
What other resources are you using for the search? 
Other Recruiter   Internal HR Department   Job board (Indeed etc.)*      

Important: This information will keep us from spending time recruiting these candidates. Please note that if a candidate is not on this list, he/she cannot be excluded from your Dental Careers contractual obligation and placement fee. Please initial that you understand this statement. 
Initials  Initials*   

Form Completed by: 

Name:   Name*   
Title:   Title*