Hill Country Dental Associates Hygienist Job Application Form- Kerrville, Texas

Registered Dental Hygienist Job Application Form

Hill Country Dental Associates 710 Hill Country Drive Suite #1 Kerrville, Texas 78028
Job Description

The Dental Hygienist plays a key role in the promotion and operations of the practice. Under direct and indirect supervision, the Dental Hygienist role is to take radiographs, update patient records, clean patient's teeth, examine the oral cavity, head and neck areas, and establish long lasting relationships with our patient family. He/She will educate patients on oral hygiene and overall oral health. The Dental Hygienist should also be able to provide practice support services including but not limited to calling patients, ordering supplies, administrative duties, and office upkeep.
General Information

Please fill out this form in its entirety and email your resume to Summer@hcfdental.com
Name:*

First NameMiddle NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Best Contact Email:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Social Security Number:*
Are you a citizen of the United States?*

YesNo
Have you ever been convicted of a crime?*
If you have been convicted of a crime, please state the offense, date and location.

Please select yes, no or unsure for the below: *

	Yes	No	Unsure
Are you at least 18 years of age?
Can you fulfill the job duties and responsibilities of the position for which you are applying as they have been described to you?
Are you available to work the hours required for the position for which you are applying?
Have you completed all Hepatitis vaccination requirements?
Can your vacations be arranged at the practice's convenience?
Do you use illegal drugs?

Professional Degree Education
Name of College or University:*
Location:*
Starting Date:*

MonthDayYear
Date
Ending Date:*

MonthDayYear
Date
Degree:*
Licenses Information
Please select your certificate/license: *
Provide your certificate/licenses number: *
Provide the Issue Date of your certificate/license: *

MonthDayYear
Date
Provide the date your certificate/license is current through: *

MonthDayYear
Date
What state issued your certificate/license blanks*
Dental Office Administrative Skills

Please select yes or no for each column along with your level of competency. *

	Yes	No	Low Level	Middle Level	High Level	None
Typing
Computer
Dental Terminology
Understanding of dental insurance policies
Appointment Scheduling
SOAP Notes
EagleSoft
Schedule Review Preparedness

Dental Office Clinical Skills

Please select yes or no for each column along with your level of competency. *

	Yes	No	Low Level	Middle Level	High Level	None
CPR Training
Digital X-Rays
Hygiene Instruction
OSHA and HIPPA Regulations
Dental Charting
Familiar with sterilization techniques
Operation of intra oral scanner- Trios
Dental Charting
Treatment Plan Presentation

Certified in Nitrous Oxide Monitoring?*

YesNoNo, I am interested in becoming certified
If you are Nitrous Oxide Certified, when does your certification expire?

MonthDayYear
Date
Are you CPR Certified?*

YesNo
If you are CPR Certified, when does your certification expire?

MonthDayYear
Date
Have you recently (within the last year) completed OSHA training?*

YesNo
Language Ability*

EnglishSpanishTurkishFrenchGermanArabicRussianJapaneseOther
Most Recent/Current Employment Information

Please tell us about your current or last employment position.
Final Position Title:*
Name of Employer/Name of Dentist: *
Phone Number:*
Please enter a valid phone number.
Address of Recent/Current Employer:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Rate of Pay: Starting Salary per hour *
Ex: per hour rate
Rate of Pay: Ending Salary per hour *
Ex: per hour rate
Average number of hours worked per week:*
Your last name at the time of employment: *
Start Date:*

MonthDayYear
Date
End Date:*

MonthDayYear
Date
Describe your duties: *
Reason for Leaving: *
Name of Dentist/Supervisor:

First NameLast Name
Dentist/Supervisor's Direct Phone Number:
Please enter a valid phone number.
Dentist/Supervisor's Direct Email Address:
example@example.com
Prospective Employment Information
Employment Desired:*

Full-TimePart-Time
Date Available to Start Employment:*

MonthDayYear
Date
Hill Country Dental Associates Operating Hours

Monday - Thursday

7:45 a.m. - 5 p.m.

*Lunch break from 1 p.m. - 2 p.m.

Friday

7:45 a.m. - 2 p.m.
Salary Range: *
Employment Reference
Company Name:*
Reference Name:*

First NameLast Name
Title:*
Phone Number:*
Please enter a valid phone number.
Email Address:
Application Questions

Please answer the following questions to complete the application.
What are you looking for in a new job/dental office? *
What responsibilities are you accustomed to or willing to do outside of your patient care role? *
What questions do you have about our office that we might be able to help answer? *
List anything additional information about yourself that you would like for us to know.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Please read the following and sign below

If hired, I will provide legal proof of identity and authority to work in the United States. I agree to conform to the rules and standards of Hill Country Dental Associates, as amended from time to time at the employer's discretion. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, will result in my dismissal from employment. I hereby certify that the information contained in this application form is true and correct to the best of my knowledge.

If hired, I understand that employment with Hill Country Dental Associates is not for a specific term and can be terminated "At Will", with or without cause, and with or without notice, at any time, either at the option of the employee or the employer. No employee or representative of Hill Country Dental Associates, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the employer may not alter the "At Will" nature of the employment relationship unless it is done specifically in writing and is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the "At Will" nature of my employment relationship. There are no oral or collateral agreements regarding this issue.

Authorization to check references:

All offers of employment are conditioned on receipt of satisfactory response to the reference requests. Unless I have otherwise indicated above, I have authorized the references listed, as well as all other individuals whom the practice may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from all liability for any damages that may result for furnishing Hill Country Dental Associates with such information as well as from the use or disclosure of such information by the employer or any of its agents, employees or representatives.
I hearby waive my right to receive a copy of any public record obtained from checking references.

Application forms will be retained for a period of 1 year.
Applicant's Signature*

Clear
After filling out this form, please email applicant resume to Summer@hcfdental.com

If you have any questions regarding this form or the information requested, please contact:

Summer West-Cazes

830-257-3000

When calling, please reference Hygienist applicant.
Please verify that you are human*
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Registered Dental Hygienist Job Application Form

Job Description

General Information

Professional Degree Education

Licenses Information

Dental Office Administrative Skills

Dental Office Clinical Skills

Most Recent/Current Employment Information

Prospective Employment Information

Employment Reference

Application Questions