Dental Assistant Application
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Educational Qualifications Certifications & Credentials
Name of College/University Attended
Year of Graduation
Highest Degree EarnedYear of Graduation
Are you a Registered Dental Assistant (RDA)?
*
Yes
No
Are you a Registered Dental Hygienist (RDH)?
*
Yes
No
Do you hold a valid California Radiation Safety license?
*
Yes
No
Do you hold a valid California Infection Control Course?
*
Yes
No
Do you hold a valid California Coronal Polishing Course?
*
Yes
No
Are you certified in CPR?
*
Yes
No
Are you certified in BLS?
*
Yes
No
Are you trained in OSHA and Infection Control protocols?
*
Yes
No
Please Upload All your Certificates (Optional)
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Work Style & Preferences
What type of work environment do you thrive in?
*
Fast-paced
Calm & Organized
Team-Oriented
Independent
Are you open to working weekends or evenings if needed?
*
Yes
No
What is your ideal schedule?
*
Full Time
Part Time
Specific Days
Which Days you can work?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is your expected hourly wage?
*
When can you start?
*
-
Month
-
Day
Year
Date
Do you prefer working in a general dental office or a specialty practice?
*
General
Ortho
Endo
Perio
Pedo
Surgical
Pediatric
Are you comfortable multitasking in a busy environment?
*
Yes
No
Are you more comfortable following instructions or taking initiative independently?
*
following instructions
initiative independently
How do you prioritize tasks when everything feels urgent?
*
How do you handle running behind schedule with multiple patients waiting?
*
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Scenario-Based & Personality Questions
A nervous patient arrives for a procedure. How would you help them feel comfortable?
*
The lead assistant is out and the doctor needs support. What would you do?
*
How do you handle conflicts with a coworker or team member?
*
A patient refuses X-rays that the doctor requires. How would you respond?
*
What are your greatest strengths as a Dental Assistant?
*
What skills or areas do you want to improve or grow in?
*
How do you stay up to date with new procedures or dental technologies?
*
What motivates you to do your best every day?
*
Where do you see yourself professionally in the next 2–3 years?
*
Are you applying for Dental School?
*
Yes
No
Are you expecting any recommendations for your future studies?
*
Yes
No
Are you interested in getting experienced in Dental Lab?
*
Yes
No
Are you interested in Dental office Front Desk work?
*
Yes
No
Are you interested in Teaching Dental Certifications?
*
Yes
No
Upload your resume here (Optional)
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If you are an Entry Level please select a date below
When are you Available for In-Person Interview (Interview will be for 15 to 30min)
If you are Experienced DA please select a date below
When are you Available for Working Interview (Interview will be for 4 Hours)
Please verify that you are human
*
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