Supervising Dentist Affidavit
American Dental Academy
9816 Southwest HWY Oak Lawn IL, 60453 (708) 663-6155
www.americandentaled.com
Coronal Scaling for Dental Assistants
In accordance with Illinois Dental Practice Act, Section 17, Paragraph 7, a dental assistant must
(1) Have at least 2,000 hours of direct clinical patient care experience AND
(2) Successfully complete an approved coronal polishing course prior to taking coronal scaling course AND
(3) Successfully complete a structured training program in coronal scaling provided by an educational institution.
I, Dr. , attest that
Dental assistant name
Meet or will meet the above criteria to attend the course on
/
/
Signature of Supervising Dentist
Date
Office address
Office stamp
City
Zip Code
Phone
Email
Note: This form must be returned to the American Dental Academy before or on the course day,
or the participant will not be able to attend this course.
Please complete, sign, and return the form or bring it to the seminar.
Print, fill, and Email to [email protected]