Job Application – Dental Medical Staffing

JOB APPLICATION FORM

Select the categories that you are interested in: Certified Medical Assistants Dental Assistants Dental Front Office Dental Hygienists Dentists Medical Assistants Medical Front Office Temp – Certified Medical Assistants Temp – Dental Assistants Temp – Dental Front Office Temp – Dental Hygienists Temp – Dentists Temp – Medical Assistants Temp – Medical Front Office

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Details

First Name *
Middle Name
Last Name *
States Lived in Last 7 Years
Date of Birth *
SSN *

Contact Info

Address *
City *
State *
Zip code *

Mailing Address – if different
City
State
Zip code

Email Address *
Home Phone
Cell Phone

Employment Info

Available to start
Permanent or Temporary	Permanent only Temporary only Both
Days Available	Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Education

Upload your Resume and References
Vocational School & College (names and dates only)
How Were You Referred?

SKILLS CHECKLIST

Receptionist/Front Office

Receptionist/Front Office Skills Check all that apply	Scheduling Recall Accounts Receivable Accounts Payable Billing and Insurance Financial Arrangements Posting charges/payments Collections Medicare/Medicaid Claims Coding Software Experience – list below

Chairside Assistant

Oregon Xray	yes
license Number

EFDA	yes
license number

EFODA	yes
license number

Washington Reg.	yes
license number

Chairside Assistant Skills Check All That Apply	Digital (sensor) Xray Digital (plate) Xray Manual Xray Invisalign Cerec Sealant Impressions Temp Crowns Manual charting Digital charting CPR certified
CPR Expiration date

Specialty Experience

Specialty Skills Check All That Apply	General Ortho Ped (o/s) Endo Oral Surgery Perio OB/GYN

Registered Hygenist

Washington RDH	yes
license number

Oregon RDH	yes
licene number

Limited Access	yes
license number

CPR Certified	yes
CPR Expiration Date

Hygenist Skills Check All That Apply	Nitrous Local Sealant High Speed Soft Reline Arestin Restorative Software Experience – list below:

Dentist

DDS/DMD	yes
Oregon License Number
Washington License Number
Idaho License Number

Malpractice Insurance	yes
Specialty Experience

Medical Assistant

Medical Assistant Skills Check All That Apply	AAMA/NCCT Certificate CPR Certified EMT Training Limited Xray Certification (LTD) Vital Signs Phlebotomy Venipuncture/blood draws Injections Urinalysis EKG’s/CBG’s Lab Testing Software Experience – list below:

Medical Biller/Coder

Meidcal Billing & Coding Skills Check All That Apply	CPT Coding ICD9 Coding ICD10 Coding HCFA 1500 UB92 Medical Claims Medicare/Medicaid Medical Collections Billing and Insurance

Medical Transcriptionist

Medical Transcriptionist Skills Check All That Apply	Digital Dictation Typing Speed Software Experience – list below

Medical Lab Tech

Lab Tech Skills Check All That Apply	Certified Lab Tech X-Ray Certified Immunology Immunohematology Hematology Microbiology Phlebotomy Urinalysis

Pharmacy Technician

Pharmacy Technician Skills Check All That Apply	Knowledge of SIG Codes for prescriptions and Dr’s orders Knowledge of pharmaceutical calculators Automated Dispensing systems (Pyxis) IV admixture Knowledge of mixing sterile products

Veterinary Assistant

Veterinary Assistant Skills Check All That Apply	Feed, water, and examine animals for signs of illness, disease, or injury Clean and disinfect cages/work areas Sterilizing lab/surgical equipment Post-operative care Administer medications orally and topically Prepare samples for lab examination, under supervision

Veterinary Technician

Veterinary Technician Skills Check All That Apply	Physical examination Dental procedure Spaying and neutering Immunizations Birthing and Euthanasia Obtain and record patient case histories Collect specimens and perform laboratory procedures Provide specialized nursing care Prepare animals, instruments and equipment for surgery Assist in diagnostic, medical and surgical procedures Expose and develop x-rays Supervise and train practice personnel Stock and maintain medicines and supplies

Veterinary Technician Skills
Check All That Apply

Physical examination
Dental procedure
Spaying and neutering
Immunizations
Birthing and Euthanasia
Obtain and record patient case histories
Collect specimens and perform laboratory procedures
Provide specialized nursing care
Prepare animals, instruments and equipment for surgery
Assist in diagnostic, medical and surgical procedures
Expose and develop x-rays
Supervise and train practice personnel
Stock and maintain medicines and supplies

DISCLAIMER AND ELECTRONIC SIGNATURE

By submitting this form, I hereby authorize Dental and Medical Staffing Inc. to make such investigations and inquiries into my employment, educational history and other related matters, as may be necessary in arriving at an employment decision. I HEREBY release employers, schools, and other persons from all liability in responding to inquiries connected with my application and for employment and I specifically authorize the release of information by any schools, individuals, services, and other entities. I HEREBY AFFIRM: That all information given by me on the pre-employment application and this employee data and work history card is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately. If selected for employment, I agree to provide documentation showing I am authorized to work in the United States of America. You may contact my former employers for references and release the information herein to your clients and insurance company. In the event of an “on the job” injury, I will submit to a post accident drug test. I will notify you when the assignment is ending and my availability for work. IF I DO NOT NOTIFY DMSI OF THIS INFORMATION THE ASSUMPTION MADE BY DMSI IS: I AM NO LONGER AVAILABLE FOR WORK AND THEREFORE QUIT DMSI. I HEREBY AFFIRM: That all information given by me on this Skills Check List is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately.

Please list agencies as well as companies you are presently engaged in the interview process with:
Additional Comments

Acknowledgement of Policies *	I have read and understand Dental & Medical Staffing, Inc policies, as stated above.
READ HERE

Acknowledgement of HIPAA *	Yes, I have read the HIPAA Privacy Rule
READ HERE

Contact Us for Your Dental and Medical Staffing Needs

Dental & Medical Staffing, Inc.

Phone: 1-800-683-0855
503-618-8367 – Portland
425-317-8367 – Washington
Fax: 503-492-2545

Job Seekers

Phone: 1-800-683-0855
503-618-8367 – Portland
425-317-8367 – Washington
Fax: 503-492-2545