I, Dr. , currently practicing at , hereby certify and attest the following:

CLINIC NAME

1. That , a dental assistant under my supervision, has
   
   Dental assistant name
2. Successfully performed six (6) dental scaling procedures on actual patients;
3. All procedures were conducted under my direct supervision, following standard dental protocols and infection control measures.
4. The dental assistant demonstrates proper technique, patient care, and competence throughout the specified procedures.
5. That I have reviewed and approved each of the six (6) scaling procedures performed;
6. This affidavit is issued upon the request of the dental assistant for submission to American Dental Academy.

IN WITNESS WHEREOF, I have hereunto set my hand this day of , 2025 at .

Signature of Dentist

Dr.

Clinic Name & Address: