Tutoring Intake Form and Consent Form
This 3 page form helps us to get to know you and pair you with the best tutor for your needs! Please review our website for pricing and frequently asked questions before completing this form.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Address (optional - but sometimes we like to send a little something your way to say thanks for working with us!)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
How did you hear about my tutoring services?
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Please Select
Social Media
Podcast
Dental Hygiene Basics Website
Google Search
Friend
Other
Please tell me a little about yourself. Where are you from? Where do you go to dental hygiene school? Are you working currently?
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What subjects are you strongest in? What subjects are you weakest in? What are your concerns? What are your biggest struggles in dental hygiene school?
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Do you require accommodations for your dental hygiene school exams or the national board exam?
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Yes
No
I am not sure
Please indicate how often you’d like to schedule tutoring:
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I am looking for a few tutoring sessions just to cover my weak areas
I am looking to meet with a tutor once a week leading up to my exam
I am looking to meet with my tutor multiple times a week leading up to my exam
Other
When is your best availability for tutoring? Please select all that apply.
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Morning (7am-12pm)
Afternoon (12pm-5pm)
Evening (5pm-8pm)
Weekends
I am totally flexible!
Please ask any questions that you have here.
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NBDHE/NDHCE QUESTIONS
This section is for students who are needing helping with national board preparation. If you are not preparing for boards, you can jump to the next page.
If you are preparing for boards, are you taking the US boards or the Canadian boards?
US
Canada
Both
Not taking boards yet
How many times have you taken the national board exam?
Tell me about your test taking experiences . What do you think went right? What do you think went wrong? What did you struggle with? Have you had similar struggles throughout dental hygiene school?
Please indicate what study material you have used to prepare for the board exams (please be specific). Examples: board prep company, mosby's textbook, darby's textbook, flashcards, etc.
When are scheduled to take the national board exam? If you are not scheduled, what date are you hoping to take the test by?
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Month
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Day
Year
Date
Are you currently using a national board prep company or have you used one in the past?
Currently using a national board prep company
I have used a national board prep company in the past
My board prep subscription has expired
I have never used a national board prep company
If you are a StudentRDH user, please include the results of your pre-assessment here.
Please upload your past national board results here if applicable.
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DH Basics, LLC Tutoring Consent Form
Thank you for choosing DH Basics, LLC (Dental Hygiene Basics) for your tutoring needs. To ensure a clear understanding of our policies and procedures, please review the terms and conditions outlined below. By signing this consent form, you agree to abide by these policies.
1. No Guarantee of Results: While our tutors are dedicated to providing high-quality tutoring and support, DH Basics, LLC does not guarantee specific academic results or outcomes. Progress depends on the effort and engagement of the student.
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2. Appointment Scheduling and Rescheduling: All tutoring appointments must be scheduled through the tutor’s online calendar. Availability is limited to the times shown on the calendar. If you need to reschedule, you must do so at least 48 hours in advance. Failure to provide adequate notice will result in being charged the full session fee.
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3. No-Show Policy: Tutors will wait up to 10 minutes past the scheduled start time for a student to arrive. After this time, the session will be considered a no-show, and the tutor is not required to remain online. No-show sessions will be charged the full session fee.
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4. Technology Requirements: To participate in tutoring sessions, students must have access to the following: A reliable Wi-Fi connection, a functional camera, and a microphone. Failure to meet these requirements may result in a suboptimal tutoring experience, for which DH Basics, LLC cannot be held responsible.
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5. Intellectual Property: All materials provided by DH Basics, LLC, including but not limited to: Session recordings, PowerPoint presentations, and Practice questions remain the property of DH Basics, LLC. These materials are for your personal use only and may not be copied, shared, distributed, or used for any other purpose without prior written permission.
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6. Consent to Recordings: DH Basics, LLC offers the option to record tutoring sessions to enhance the learning experience. These recordings are intended for the student’s personal review only. By default, sessions will not be recorded without the student’s or, if applicable, the parent/guardian's explicit consent. You may choose to consent to the recording of your sessions by indicating your preference below.
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I consent to the recording of my tutoring sessions and understand that these recordings will be made available to me for personal review only.
I do not consent to the recording of my tutoring sessions.
5. Access to Session Recordings: Students will have access to recordings of their tutoring sessions for review purposes. These recordings are for the student’s personal use only and may not be shared or distributed. Students will have access to these videos until they pass their exams. After successfully passing the exams, the videos will be deleted and no longer accessible.
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8. Dispute Resolution: In the event of any disputes, claims, or disagreements arising out of or relating to tutoring services provided by DH Basics, LLC, both parties agree to resolve such matters through arbitration. Arbitration Agreement: Any dispute will be settled exclusively by binding arbitration, conducted by a mutually agreed-upon arbitrator, in accordance with the rules of the American Arbitration Association or a similar recognized arbitration organization. Location and Costs: Arbitration shall take place in a mutually agreed-upon location. Each party will bear its own costs, including legal fees, associated with the arbitration, unless otherwise decided by the arbitrator. Final and Binding Decision: The decision of the arbitrator will be final and binding on both parties, and judgment on the award rendered by the arbitrator may be entered in any court of competent jurisdiction. Waiver of Court Proceedings: By agreeing to arbitration, both parties waive their rights to bring any disputes to court, including the right to a jury trial. By signing this consent form, you acknowledge and agree to resolve disputes through arbitration as outlined above.
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