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CORONAL POLISHING AND DENTAL SEALANTS

REGISTRATION FORM

MAIL-IN REGISTRATION FORM - ONE FORM PER PERSON PLEASE - THIS FORM MAY BE DUPLICATED.

02/01/13 02/02/13

COURSE TITLE Coronal Polishing Dental Sealants

FEE $ 750

MAIL THIS FORM WITH PAYMENT TO: Sinclair Community College Dental Health Sciences Department 444 West Third Street Dayton, OH 45402-1460 Phone: 937-512-2779 FAX: 937-512-4175

EXP. DATE _______________________

M/C

VISA

CARD # ______________________________

C V V # ________

(THIS IS THE NUMBER ON THE BACK OF YOUR CREDIT CARD.)

CARD OWNER'S NAME IF OTHER THAN STUDENT ______________________________________________ STUDENT NAME ___________________________________________________________________________ HOME ADDRESS ___________________________________________________________________________ CITY ___________________________________________ STATE ZIP CODE __________________

HOME PHONE: ________________________________ BUSINESS PHONE: ___________________________ EMPLOYER'S NAME ________________________________________________________________________ ADDRESS _________________________________________________________________________________ CITY ___________________________________________ STATE _________ ZIP CODE __________________

WITHDRAWAL & REFUND POLICY A handling fee, 50 percent of the total cost, will be charged when cancellations are made less than one week prior to the seminar. A handling fee, 25 percent of the total cost, will be charged when cancellations are made at least one week prior to the seminar. Full refunds will be made automatically in the event of institutional cancellations. No-shows are responsible for the entire amount.

Coronal Polishing for the Certified Dental Assistant SEVEN CEU'S Approved by the Ohio Dental Board

This 7 hour continuing education course will prepare the Certified Dental Assistant for coronal polishing techniques on the clinical crowns of the teeth. There are specific indications and contraindications for doing a coronal polish. Participants who successfully complete the course may obtain coronal polishing certification in the State of Ohio.

Presenter: Theresa Bonn, RDH Fee:

*$400 includes all supplies, lunch, refreshments and parking

Friday, February 1, 2013 Registration: Lecture: Clinical: Standardized Exam:

Location: Sinclair Community College Date: 8:15 am 8:30 - 11:30 am 12:30 - 4:30 pm 4:30 - 5:30 pm

Registration Deadline: January 18, 2013 Capacity is limited to 20 students on a first come first serve basis with complete eligibility. Sinclair reserves the right to cancel the course with a full refund due to insufficient enrollment. Eligibility for the Certification of Coronal Polishing Course at Sinclair Community College requires the following items along with a completed application and full payment by the registration deadline:

1. A copy of CURRENT Certified Dental Assisting Certification (Ohio or DANB) showing expiration date 2. A copy of CURRENT CPR certification 3. After the above has been received, a medical history will be sent to you and MUST BE RETURNED/MAILED to SCC before January 25, 2013. 4. We highly recommend that candidates have a complete scaling or oral prophylaxis within 3 months of the course date.

For additional information contact Judy Fronsoe, 937-512-2779 or [email protected]

*Participants interested in both the Coronal Polishing and the Dental

Sealants seminars may attend both for a reduced rate of $750.00.

Dental Sealants for the Certified Dental Assistant

EIGHT CEU'S Approved by the Ohio Dental Board This 8 CEU continuing education course will prepare the certified dental assistant in the proper placement of dental sealants. This course focuses on two didactic hours including dental anatomy, infection control, legalities, and placement technique. Six clinical hours concentrates on demonstration, practice and clinical competency. Presenter: Sinclair Community College Dental Health Sciences Faculty Fee:

*$400.00 includes all supplies, lunch, refreshments and parking

Saturday, February 2, 2013 Registration: Lecture: Clinical: 8:15 a.m. 8:30-11:30 am 12:30-4:30 pm

Location: Sinclair Community College Date:

Standardized Exam: 4:30-5:30 pm Registration Deadline: January 18, 2013 Capacity is limited to 20 students on a first come first serve basis with complete eligibility. Sinclair reserves the right to cancel the course with a full refund due to insufficient enrollment. Eligibility for the Certification of the Dental Sealant Course at Sinclair Community requires the following items be submitted along with a completed application and full payment by the registration deadline: 1. A copy of CURRENT Certified Dental Assisting Certification (Ohio or DANB) showing expiration date 2. We require that candidates wear scrubs, lab coats; hair pulled back and off the collar, minimal jewelry, and must bring their own safety glasses. For additional information call Judy Fronsoe, 937-512-2779

*Participants interested in both the Dental Sealants and Coronal Polishing

seminars may attend both for a reduced rate of $750.00.

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Coronal Polishing

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