Doctor’s Profile

Doctor Profile

Doctor's Name:

DMD DDS General Practitioner Specialist

Home Address:

Home Phone Number: Cell Phone Number:

Marital Status: Spouse Name (if applicable):

Sex: Male Female

SSN:

Date of Birth:

State Of Birth: Country of Birth (if outside of US): NPI #:

Practicing Hand Left Right

Check One (Optional) White Black (not of Hispanic origin) Hispanic American Indian Asian Other

Emergency Information

Contact Name: Relationship:

Address:

Phone Number:

Educational Background

Undergraduate University: Month & Year of Graduation:

Dental School: Month & Year of Graduation:

Specialty Training: Month & Year of Graduation:

Internships (if any): Month & Year of Graduation:

Residency (if any): Month & Year of Graduation:

Post-Graduate Programs (if any): Month & Year of Graduation:

Dental Licensure (please have copies of the following)

State of Licensure: License Number: Expiration Date:

State of Controlled Substance: CSR Number: Expiration Date:

DEA: DEA Number: Expiration Date:

Work History

For the last five years, please provide us with the name and address of each location where you have practiced. Please include the month and year for the Start and End Dates.

Practice Name	Location (City and State)	Start Date	End Date

List any Professional Organization of which you are members (ADA, State Dental Society, etc)

List any awards, achievements or accomplishments which would be of interest to prospective patients

List your personal interest or hobbies

List below any community involvement you are currently or have participated in

What do you enjoy most about practicing dentistry?

List any insurance plans you are already credentialed with

List any foreign languages spoken

Malpractice Coverage: (please have a copy of declaration page)

Current Carrier: Carrier's Phone Number:

Policy Number: Amount of Coverage: Dates of Coverage:

Please list any previous malpractice insurance carriers below:

Previous Carrier	Policy # (Do Not Fill Out Online)	Start Date	End Date

Please answer the following questions:

1. Do you have hospital privileges?	Yes	No
Hospital:
2. Do you prescribe drugs?	Yes	No
3. Are you an ADA member?	Yes	No
4. Do you have Specialty Training?	Yes	No
5. Are you board certified?	Yes	No
6. Are you board eligible?	Yes	No

Please answer the following questions, if you answer “yes” to any of the following, please explain below:

1. Have you ever been cited for violations of your state’s dental practice act?	Yes	No
2. Have you ever been cited for violations in other state in which you have practiced?	Yes	No
3. Have you ever been cited by the Drug Enforcement Administration for narcotics or other controlled substance violations?	Yes	No
4. Have you ever committed any act or acts which would render you morally or professionally unqualified to render services?	Yes	No

Please answer the following questions, if you answer “no” to any of the following, please explain below:

1. Do you follow all proper emergency protocol as recommended by the ADA, Centers for Disease Control, OSHA, and all other governing local, State and federal authorities?	Yes	No
2. Do you follow all proper sterilization protocol and barrier techniques as Recommended by the ADA, Centers for Disease Control, OSHA, and all Other Governing local, state and federal authorities?	Yes	No
3. Do you follow all proper radiation and chemical protocol as recommended By the ADA, Centers for Disease Control, OSHA, and all other governing Local, state and federal authorities?	Yes	No

Statement

I hereby acknowledge that the above completed information is true and factual.

Name: Date:

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