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 (such as a dental school or a dental hygiene or dental assisting program) or by a statewide dental or dental hygienist association approved by the Illinois Department of Financial and Professional Regulation (IDFPR) that includes the following: (a) minimum 32 hours of didactic and clinical manikin or human subject instruction covering specified content, (b) an outcome assessment examination that demonstrates competency, (c) completion of 6 full-mouth scaling procedures under the observation and with approval of the supervising dentist, (d) issuance of a certificate of completion (which must be kept on file at the dental office).
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 or 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]
