Daily Dental Solutions, inc.
PO Box 594, Piedmont, OK 73078
Office: 405-373-3299
Email: Sheresa@DDS4you.com
Digital Assignment Slip
Name of Temporary
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Temporary's Email:
*
example@example.com
Dentist Name or Name of Company working at
*
First Name
Last Name
Dental Office Name
*
Company Name
Location
Dental Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hourly Rate for Temporary:
*
Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Monday Hours worked
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Monday Lunch Break
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Fee Owed to Temporary
Tuesday Hours worked
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Tuesday Lunch Break
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Fee Owed to Temporary
Wednesday Hours worked
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Wednesday Lunch Break
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Fee Owed to Temporary
Thursday Hours worked
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Thursday Lunch Break
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Fee Owed to Temporary
Friday Hours worked
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Friday Lunch Break
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Fee Owed to Temporary
Saturday Hours worked
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Saturday Lunch Break
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Fee Owed to Temporary
If Applicable Cancellation: Temporary cancelled with less than a 24-hour business day notification
*5-hour minimum due
Date & Fee Owed to Temporary for cancellation with less than a 24 hour business day notice:
If Applicable Drive Fee: Must be approved. Drive fee(s) owed to Temporary for commuting outside of their area.
I have filled out the information completely & accurately. I agree not to accept any additional temporary or permanent work from this office, anyone associated with this office, or affiliates of this office without the express knowledge & consent of DDS, inc. I am not to give out any personal phone numbers to dental offices. Signature of Temporary
*
Dental Office Use only: To be filled out by the Dentist or Employee of the dental office: Email you would like assignment slip sent to:
*
example@example.com
Dental Office Use Only: Printed Name for Signature Below
*
First Name
Last Name
Dental Office Use Only: I agree to abide by the terms & conditions set forth in the signed agreement with DDS, inc. I, nor any employees, associates, affiliates/subsidiaries, or otherwise will solicit any DDS, inc. Temporary for work on a temporary or permanent basis without the express knowledge & consent of DDS, inc. We are not to contact DDS, inc. Temporaries directly. All contact goes directly through DDS, inc. Signature of Dentist or Office Manager
*
SUBMIT WHEN ASSIGNMENT IS COMPLETE
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