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
Download PDF 
————————————————————————————————————————
American Dental Academy 9816 SW Hwy Oak Lawn Il, 60453 (708) 663-6155
Coronal Scaling for Dental Assistants
Supervising Dentist Affidavit
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, _______________________________, attest that ___________________________ meets or
will meet the above criteria to attend the course 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]