Pit & Fissure Sealants & Coronal Polishing Wisconsin

Participants will be required to place at least 6 Pit and Fissure Sealants under the observance of their supervising Dentist. Upon successful completion of the lecture, clinical instruction, and return of verification of sealant placement form, participants will receive a certificate to perform Pit & Fissure Sealants.

Name of Dental Assistant

Employer Dentist(s):

Name Of Doctor *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Number of Sealents

Numbers

Numbers (copy)

Numbers (copy) (copy)

Patients initials

Name *

Date

Doctors Signature

November 13th 9:30am-1:30pm, Location 7777 West North Ave. River Forest, Il 60305-FULL

December 11th 9:30am-1:30pm, Location 7777 West North Ave. River Forest, Il 60305

Illinois Coronal polishing and Pit and Fissure Sealants