Course Registration Form

Application for Orthodontic Expanded Duties Functions Module
Applicant Information

By completing this form you hereby agree that you have a minimum of six months experience as a dental assistant or have graduated from an ADA Accredited Dental Assisting Program and have been trained on a typodont in Procedures in the Florida State Board of Dentistry, rule 64B5-16.005 and 16.008. The fee for the certification module is $150.00, and includes both the orthodontic expanded duties and the orthodontic clinical crown tooth polishing modules.
Name

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Email Address
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Phone Number
Format: (000) 000-0000.
Address

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Employer Information

Employer must sign off prior to testing
Name of Employer
Employer Phone Number
Format: (000) 000-0000.
Employer Email
example@example.com
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CityState

Zip Code
Module and Location

Please open the PDF in your email for important information after submitting the form.
Have you taken Orthodontic Expanded Functions module previously?
If so, when? Date
Have you taken Orthodontic Tooth Polishing module previously?
If so, when? Date
Module to be taken
Test Site
If you are looking to register more than one orthodontic assistant for the November Naples course, please reach out to Abby Morken at info@faortho.org. THERE IS ONLY ONE SPOT LEFT FOR THE NOVEMBER NAPLES COURSE.
Payment

Expanded Duties Module

The fee includes both the orthodontic expanded duties and the orthodontic clinical crown tooth polishing modules. If you are currently certified in one of these areas, your attendance and participation in that area is not required. However, the fee is not reduced if only one portion is taken.

$150.00

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Application for Orthodontic Expanded Duties Functions Module

Applicant Information

Employer Information

Module and Location

Payment