Request Help

Use this form to request an employee placement through Dental Express Staffing.

Practice Name

Location

Contact Person

Phone Number

After Hours Phone Number Contact # for unexpected schedule changes

Date(s) Needed

Patient Hours Substitute will arrive 30 minutes earlier

Employee Position

RDH

Admin

Notes

Updates Only if there have been changes since last DES request

Current Software Being Used Only if there have been changes since last DES request

Current Dentist(s) Employed Only if there have been changes since last DES request

Willing to pay mileage if necessary?

Yes

Other Clients Forms

New Client

Cancel Date(s)