Dental Nurse Application Form "*" indicates required fields Step 1 of 6 – Personal Information 0% Personal DetailsMarital Status*SingleMarriedDivorcedWidowedSeparatedDomestic PartnershipNationality*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsName* Title Mr.Mrs.MissMs.Dr.Prof.Rev. First Name Surname Date of Birth* Day Month Year Email* National Insurance Number* Mobile Number*Home TelHome Address* Street Address Address Line 2 Town/City County Post Code Next of Kin (NOK)Please provide details for who should be contacted in case of emergency.NOK Name NOK First Name NOK Surname Relationship NOK Mobile NumberNOK Email Address NOK Home Address Address Line 1 Address Line 2 (optional) Town County Post Code Professional DetailsQualification(s) Held* GDC Registration Number* Has there been any proceedings of negligence or professional misconduct against you, and have you ever been suspended or dismissed from your employment?* Yes No Briefly Supply Details*Dental Practice Experience Dental Anaesthesiology – Assisting with the administration and monitoring of anaesthesia in dental procedures. Dental Implantology – Assisting in the placement and maintenance of dental implants. Dental Public Health – Focus on preventing and controlling dental diseases through community-wide efforts. Endodontics – Specialising in root canal treatment and diseases of the dental pulp. Forensic Dentistry – Working in settings that require identification of individuals through dental records. General Dental Practice – Assisting with all clinical aspects of dental care (e.g., fillings, root canals, crowns). Geriatric Dentistry – Treatment of elderly patients. Maxillofacial Unit – Assisting in a setting where the focus is on the face, jaw, and neck. Mobile Dental Clinics – Providing dental care in non-traditional settings, such as schools, community centers, or remote areas. Oral Surgery – Supporting in procedures such as extractions and oral surgeries. Orthodontics – Assisting with the fitting of braces and other dental alignment procedures. Paediatric Dentistry – Specialised care focused on children, from routine checks to specific treatments. Periodontics – Assisting in the treatment of gum diseases and conditions. Prosthodontics – Assisting in the creation and fitting of dental prosthetics (e.g., dentures, crowns). Radiology – Experienced in taking and processing dental X-rays. Sedation Clinic – Assisting with the management of patients undergoing dental treatments under sedation. Special Care Dentistry – Working with patients who have special needs and require unique dental care approaches. Travel & Work PreferencesAre you a Driver?* Yes No Would you temporarily relocate for work (with accommodation)? Yes No How many hours are you available to work each week? Under 12 Hours 12 – 24 Hours 24 – 36 Hours 36+ Hours How far are you willing to travel for work?Enter Distance or Travel Time. Please choose your preferred shift patterns Days Nights Weekends Flexible for any Do you have a DBS Certificate that is registered on the Update Service? Yes No Rehabilitation of Offenders ActBecause of the nature of the work for which you are applying, Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 applies. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.Have you at any time been convicted of an offense?* Yes No If 'Yes', Briefly Supply Details*Disclosure & Barring ServiceDBS Consent 1* I agree that Center Healthcare can access the DBS update service portal to check for any changes to my DBS clearances as and when necessary.*DBS Consent 2* I undertake to inform Center Healthcare should I be convicted of an offence in the future.* HiddenInductionHiddenInduction I have received a copy of the induction pack and can confirm that I am aware that more information can be found in the Agency Worker Handbook and all Policies can be obtained directly from www.centerhc.com/policies. HiddenInduction I have received (or downloaded) the company handbook and have understood and will always comply with it. I am aware that any amendments or new versions will be available at www.centerhc.com/downloads HiddenHepatitis BHiddenHep B I have been advised at registration of the importance of having the Hepatitis B vaccine.HiddenHep B I acknowledge that I have been/am being vaccinated against Hepatitis B and will continue to maintain my immunity.HiddenHep B I accept responsibility for my decision, and I will ensure that I take all precautions to avoid contracting the illness and avoid accepting work within environments which are hazardous. Data ProtectionGDPR1 I agree that Center Healthcare retains the right to hold this application and any other data required to process it and to pass on to any authorised third party for the purposes of audit and work placements. GDPR2 I agree that Center Healthcare can retain these details for as long as reasonably necessary in accordance with the Data Protection ActGDPR3 I understand that I am responsible for ensuring that my personal compliance such as my GDC registration, DBS update service and mandatory annual training are kept up to date. If any of my compliance items lapse, it may cause the suspension and/or termination of my placement and I will be unable to work until my compliance items are updated.Terms & ConditionsT&C 1 I confirm that the information given in this application is, to the best of my knowledge, true.T&C 2 I understand that my registration is subject to the receipt of at least two satisfactory references and an enhanced disclosure from the Disclosure and Barring Service (DBS).T&C 3 I undertake to inform Center Healthcare immediately if I am engaged through their introduction, including the offer of permanent employment following a temporary assignment.T&C 4 I agree to respect the confidentiality of patients and any other information I may have access to, at all times.T&C 5 I understand that Center Healthcare cannot guarantee assignments and that they have no responsibility to pay for hours not worked no matter the situation.HiddenHep B I have read, understood and agree to the terms & conditions of work for temporary nurses, of which I have been given a copy or have downloaded from Center Healthcare’s website.CAPTCHASignature*Sign Date* DD slash MM slash YYYY
