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

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

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