Application Form | Smiles Dental Training

enquiries@smilesdentaltraining.co.uk | 07534490719

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Full name *

Date of Birth *

Home Address *

Postcode *

Contact Number *

Email address *

Do you consider yourself to have any learning difficulties, disabilities, or additional support needs?"

No
Yes

GDPR - I am happy to be contacted via email for the following:

Newsletters
Latest course offers and promotions
Request for feedback

Consent may be withdrawn at any time by emailing enquiries@smilesdentaltraining.co.uk

Employer Information

Employer name *

Manager name *

Practice address *

Contact number *

Email address *

Supervising Dentist name *

Supervising Dentist GDC number *

Previous employment - please list Employer, from-to dates and Job Title

Competencies

In order to complete the course, competencies must be demonstrated. The employer must sign below in agreement that the following competencies can be achieved. Please confirm you can carry out the following procedures within practice:

Preparing and maintaining the clinical environment *

Yes
No

Sterilisation process *

Yes
No

Disinfection of impressions *

Yes
No

Assisitng with preventative treatment *

Yes
No

Assisting in the taking and processing of radiographs *

Yes
No

Cavity restoration procedure *

Yes
No

Endodontic procedure *

Yes
No

Fixed prosthesis procedures *

Yes
No

procedure Employer process

Removable prosthesis procedures *

Yes
No

Extraction procedures *

Yes
No

Local anesthetic procedures *

Yes
No

Employer Signature (digital - type name) *

Identification

I have attached a copy of one or more of the following as proof of identification:

Driving Licence
Provisional Driving Licence
Passport
Other

Agreement

I wish to enrol the applicant on the NEBDN Diploma in Dental Nursing with Smiles Dental Training LTD. I confirm that I have the necessary training in place in order to complete the course, and Portfolio of Evidence as set out by the NEBDN

Name of applicant *

Date (dd/mm/yy) *

Manager/Supervising Dentist *

GDC Number *

We offer either payment in full or monthly instalments. *

Pay in full
Monthly installment plan

Smiles Dental Training provides leading education in dental care, specialising in National Diploma and Post-Registration courses. Our programs are built around a flexible and effective online model, led by a team of experienced and passionate dental professionals to help you achieve outstanding results.

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Address

Meadow View
Potter Heigham Road
Catfield
Norfolk, NR29 5BU

Contact Us

enquiries@smilesdentaltraining.co.uk

07534490719