Dentistry, air abrasion, root canal, whitening, dental fear


*Name of Dentist:
*Name of Dental Practice:
Address Line 1:
Address Line 2:
City/State/Zip:	/ /
*Phone Number:
Website:
*Email:
Affiliations:
Years in Practice:
Are you in a group practice, names of associates:
*Have you ever been convicted of any crime (other than a minor traffic violation)? If so, please explain.
*Have you had your dental license or privilege to prescribe controlled substances suspended or revoked, or have had any disciplinary action taken against your dental license? If so, please explain.
*Has a malpractice claim ever been filed against you and settled in favor of the plaintiff? If so, what were the circumstances and the amount of the judgment?
*Do you have any habits or addictions that could impact competent care of your patients?
*Reasons for wanting to participate:
( = required field )*

*Human code:

Retired Professional Football Players Program Application