Doctor Registration

Please fill out the below form to create an account. Please allow up to 24hrs for your account to be activated. Once activated, you will have access to all necessary forms needed to use our service, reserve temporary staff, pay Placement Fees, and other pertinent information. All information entered in this form is strictly confidential.

Please enter a username.

Account Info

Username *

E-mail *

Password *

Password must be at least 7 characters long. To make it stronger, use upper and lower case letters, numbers and symbols.

Confirm Password *

Type your password again.

 

Strength Indicator

Location *

Northern Arizona Central Arizona Southern Arizona

Doctor's Name *

Doctor's AZ License # *

Name of Practice *

Practice Address--Street *

Practice Address--City and State *

Practice Address--Zip Code: *

Office Contact/Manager *

Practice Phone # *

Practice Fax # *

Practice Email *

Confidential Email (for invoices) *

After Hours Contact (name and phone number) *

After Hours Phone # *

Office Type *

General Dentist Pediatrics Orthodontics Endodontics Peridontics Oral Surgery Prosthodontist

Dental Software *

X-Ray System/Software *

On what day(s) is your office open? *

MondayTuesdayWednesdayThursdayFridaySaturday

What are your normal office hours? *

Will you accept a new graduate (<1 year experience?) *

Yes No

Years of experience required *

1-2 years 2-5 years 5+ years

Will you accept a hygienist not anesthesia certified? *

Yes No

Do you require a bilingual candidate? *

Yes No

How did you hear about us? *

Dental Temps AZ visited my office Referred by another dental office Internet search Direct mailer to doctor Direct mailer to hygienist Other

Who can we thank for referring you to our service? *

Robot Detection  *

 

Register