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SUPERVISING DENTIST Statement undersigned LICENSED DENTIST acknowledges that he/she has read and understood the attached Consent Order and agrees to serve as, Supervising Dentist. Sworn to and subscribed

How to fill out supervising dentist statement

How to fill out supervising dentist statement

1. To fill out a supervising dentist statement, follow these steps:
2. Start by indicating the name of the supervising dentist at the top of the statement.
3. Provide the contact information of the supervising dentist, including their address, phone number, and email.
4. State the purpose of the statement, which is to confirm the supervising dentist's role in overseeing your dental practice.
5. Include a brief description of the supervising dentist's qualifications and experience in the field of dentistry.
6. Clearly state the dates or time period during which the supervising dentist has been involved in supervising your practice.
7. Provide any additional details or specific responsibilities the supervising dentist has in relation to your practice.
8. Ensure both you and the supervising dentist sign and date the statement to certify its accuracy.
9. Keep a copy of the completed statement for your records.

Who needs supervising dentist statement?

1. The supervising dentist statement is typically required by dental regulatory bodies or licensing boards.
2. It is needed by dentists who are practicing under the supervision of another licensed dentist.
3. Dental students or recent graduates who are completing their residency or internship may also require a supervising dentist statement.
4. This statement serves as proof that a qualified dentist is overseeing and taking responsibility for the dental practice being supervised.

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What is supervising dentist statement?

The supervising dentist statement is a document submitted by a dentist who is supervising a dental hygienist or dental assistant.

Who is required to file supervising dentist statement?

The supervising dentist is required to file the supervising dentist statement.

How to fill out supervising dentist statement?

The supervising dentist must provide information about the dental hygienist or dental assistant they are supervising, along with any other required details.

What is the purpose of supervising dentist statement?

The purpose of the supervising dentist statement is to ensure that proper supervision is being provided to dental hygienists and dental assistants.

What information must be reported on supervising dentist statement?

The supervising dentist must report information such as the name of the dental hygienist or dental assistant being supervised, the dates of supervision, and any relevant details about the supervision provided.