Shadowing Interest Form

Shadowing Interest Form - Makkah Community Dental Clinic (MCDC)

For students and pre-dental / pre-health applicants who want to observe at our Sunday clinic.
Welcome! Makkah Community Dental Clinic (MCDC) is a nonprofit clinic in Garland, TX that treats uninsured and underserved patients on Sundays, 8 AM to 2 PM. We are glad to host students who want to see community dentistry up close.

A few things to know before you sign up:
- Shadowing is observation only. No patient contact or hands-on care.
- We host one shadower per clinic day, so we will confirm your date by email or text after you submit this form.
- Shadowers must be 18 or older and follow our confidentiality (HIPAA) and infection-control rules.
- Wear scrubs and closed-toe shoes, and arrive 15 minutes before the clinic opens.
Clinic address: 3301 W Buckingham Rd, Garland, TX 75042. Questions: info@mcdc.care
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Are you 18 or older?
School and program
e.g., UT Dallas - Biology (pre-dental)
Where are you in school?
What are you hoping to get out of shadowing?
e.g., dental school application hours, exploring the field, a procedure you want to see
Approximate dental shadowing hours so far
Enter 0 if this would be your first time.
Which clinic days work for you? (8 AM - 2 PM)
Earliest date you could start, and any dates you cannot make
e.g., any Sunday after Oct 4; not Nov 29
Shadowing Observer Agreement

As a shadowing observer at Makkah Community Dental Clinic (MCDC), I agree that: (1) I am observing only and will not touch patients, instruments, or equipment, or provide any care; (2) all patient information I see or hear is confidential under HIPAA. I will not record, photograph, copy, or discuss it outside the clinic, and this obligation continues after my shadowing ends; (3) I will follow the directions of clinic staff and volunteer dentists at all times, including infection-control rules, dress code, and any request to step out of a treatment area; (4) I will not present myself to patients as a clinician or student clinician; and (5) the clinic may end my shadowing at any time. I understand that shadowing is unpaid and that the clinic makes no commitment to a set number of hours.
I have read and agree to the Shadowing Observer Agreement above.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Shadowing Interest Form - Makkah Community Dental Clinic (MCDC)