Supervising Dentist Affidavit
American Dental Academy 9618 SW. Hwy Oak Lawn, IL. 60453 (708) 663-6155
Coronal Polishing and Application of Pit & Fissure Sealants Course
By Section 1220.245 of the Rules for the Administration of the Dental Practice Act of the State of Illinois, a dental assistant must be at least 18 years of age with 1000 hours of clinical dental assisting experience or have graduated from a dental assisting program accredited by the Commission on Dental Accreditation of the American Dental Association, or be certified as designated by the Dental Assisting National Board, Inc to perform Coronal Polishing and Application of Pit and Fissure Sealants.
I, _______________________________, attest that ___________________________ meets or
will meet the above criteria to attend the above courses on / /
_________________________________________
Signature of Supervising Dentist Date
Illinois License #____________________________
Note: This form must be returned to the American Dental Academy before _____________ or the participant will not be able to attend this course.
Please return the form via:
Print and E-mail to [email protected]
American Dental Academy
