Verification Form

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.

     
    Employer Dentist(s):

     
     


    Number of sealants

    Patients initials

    Date

    Doctor’s initials after successful completion

    1

    2

    3

    4

    5

    6