Practice Information

Practice Name *

Owner/Primary Contact *

Email Address *

Phone Number *

Practice Address *

Website (if applicable)

Practice Profile

Type of Practice

General Dentistry

Pediatric

Orthodontics

Periodontal

Multi-Specialty

Other

Number of Operatories/Chairs

Practice Size *

Solo

small group

large group

multi-location

Hours of Operation *

Software/Systems in Use *

Dentrix

Eaglesoft

Open Dental

other

Staffing Needs

Roles Needed *

Hygienist

Assistant

Office Manager

Treatment Coordinator

Front Desk

Other

Type of Hire *

Contract

Contract-to-Hire

Permanent

Per-Diem/Temp

Number of Open Positions *

Desired Start Date *

Work Schedule *

Full-time

Part-time

Flexible/As Needed

Requirements & Preferences

Certifications or Skills Required (e.g., Radiology, Anesthesia, Expanded Functions, Insurance Billing) *

Years of Experience Preferred *

Cultural/Team Fit Notes (describe ideal candidate personality, work style, or values) *

Pay Rate or Salary Range (optional but encouraged for faster matches)

$

Compliance & Agreements

Do you require background checks? *

Yes

No

Do you require drug screening? *

Yes

No

Who will handle onboarding/training at your practice? *

Authorization & Next Steps

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I consent to receive non-marketing text messages from CoreEthos Group about my order updates, appointment reminders etc. Message & data rates may apply.

Signature *

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