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, Dr. _______________________________, attest that ___________________________
Dental assistant name
meets or will meet the above criteria to attend the courses on / /
Signature of Supervising Dentist —————————————– Date
*Office Name Or Office Stamp
*Address:
*City
*Zip code
*Phone:
*Email address
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
