Post a Position (Detailed) Please fill out the form below Practice Contact InformationPractice Legal Name AKA Practice Name #1 AKA Practice Name #2 Doctor Name Practice Contact Person Practice Contact Title Practice Contact Email* Practice Contact PhoneSpecial Contact Instructions Secondary Contact Name First, Middle and LastSecondary Contact Title Secondary Contact Email Secondary Contact Cell PhoneCorporate StructureSelectP.A.P.C.Inc.L.L.C.L.L.P.P.L.L.C.FQHCPractice Website Please include the full URL, including http:// or https:// Practice AddressPractice Street Address Practice City* Practice State*SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYPractice Zip Practice County Office Phone Office Fax Nearest major city #1 to your practice Nearest major city #2 to your practice Position InformationPosition Title*SelectPlease SpecifyGeneral DentistOral SurgeonOrthodontistEndodontistPeriodontistProsthodontistPediatric DentistDental DirectorNon-ClinicalPosition Type*SelectPlease SpecifyFull TimePart TimeFull or Part TimeTemporaryConfidentialSelectYesNoPart Time # of DaysSelect1 Day/Week2 Days/Week3 Days/Week4/Days/WeekOther- Please Indicate in Part Time/Temporary DetailsTemporary # of DaysSelect30 Days60 Days90 Days180 DaysOther- Please Indicate in Part Time/Temporary DetailsPart Time / Temporary Details* Position DescriptionJob Location/sSelectSingle LocationMultiple Site JobMultiple Location/Job Descriptions*Position Available Effective Required Skills / Traits Desired Preferred Skills / Traits Position / Recruit InformationOwnership Opportunity Offered?SelectYesNoOwnership Offered When?* Compensation Structure Who Pays Associate's Lab Fees? Other Employment Benefits Managerial / Supervisor Responsibilities? Other Practice Information to Disclose to Candidate Willing to Hire New Graduate? Willing to Hire New Graduate?Minimum Experience Level Required--None--GPR+AEGD+Must be Graduated1+2+3+4+5+6+7+8+9+10+ Language / Sponsorship InformationWilling to Sponsor? Willing to Sponsor?If Willing to Sponsor, Please Enter Details BelowLanguages Required English Spanish Mandarin Tagalog Vietnamese Hebrew Russian French Other Specify Other Language(s) Practice StaffNumber of AssistantsNumber of HygienistsNumber of Other StaffAssociate Names Practice Production% Practice Income from Cash% Practice Income from HMO% Practice Income from PPO% Practice Income from Capitation% Practice Income from MedicaidTotal Gross ProductionPractice Serves Children?SelectYesNoAge Range of Children Seen Number of Active Patients (last 18 months)Average Number New Patients / MonthHow Far Ahead is Dentist Scheduled? Office HoursMonday Office Hours Tuesday Office Hours Wednesday Office Hours Thursday Office Hours Friday Office Hours Saturday Office Hours Sunday Office Hours Facility / Office RelatedOffice Square FootagePlease enter a number less than or equal to 99999.Own or Lease Practice OfficeSelectOwnLeasePractice R/L HandedSelectRightLeftBothRear DeliveryAllOffice Computerized?SelectYesNoPartiallySoftware Used Total Number of Equipped OperatoriesPlease enter a number less than or equal to 99.Please Give Any Highlights and Description of Your Community Account InformationWhat is your Henry Schein Account Number? Position SourceHow You Heard About Us Regulatory RelatedOSHA Compliant OSHA CompliantAny Disciplinary Actions Last 7 Years?SelectYesNoDisciplinary Action DetailsAny Practice Lawsuits?SelectYesNoPractice Lawsuit DetailsList Any Candidates to Avoid in Our Search and Why?Any candidates not disclosed will be considered a candidate of Henry Schein Nationwide Dental Opportunities upon submission of their information to Client. Per your signed contract with HSNDO, "Client agrees to pay HSNDO a recruiting fee if and when: (a) a candidate referred by HSNDO begins any opportunity or becomes associated professionally with Client in any way; and (b) for any other candidate hired by Client within six months of a candidate’s placement that were referred to Client by a candidate presented by HSNDO." Please sign off on the following policies and procedures: I am aware that HSDRS must send all eligible candidates for my practice opportunity with no bias of race, color, religion, creed, national origin, ancestry, disability that can be reasonably accommodated without undue hardship, sex, sexual orientation, age, citizenship, marital or veteran status or any other legally protected status. I am free to hire the most suitable candidate for my opportunity, however all resumes will be considered. I am aware that an initial candidate pool exists comprised of individuals who have been screened and interviewed by HSDRS for the purposes of locating a position in my state. However, I acknowledge that HSDRS has not performed a background check and/or drug screen on prospective candidates and makes no warranties and/or representations with respect to a candidate 's criminal history. It will be my responsibility to perform the background check and/or drug screen on prospective candidates. Further, I am aware that candidates presented have no firsthand knowledge of my practice opportunity until presented by HSDRS. I agree to keep strictly confidential all candidate information and will not, without HSDRS 's express written authorization, signed by one of HSDRS 's authorized officers, use, sell, market, or disclose any confidential information to any third person, firm, corporation, or association for any purpose. I will not circumvent or impede HSDRS 's progress in presenting my opportunity to qualified prospective candidates. I will allow HSDRS to perform their responsibilities and will not present the opportunity on my own or contact candidates provided by Nationwide without their consent. HSDRS shall be due its recruiting fee for any candidate presented by HSDRS that is hired by the practice and for any other candidates hired by the practice within six months of a candidate 's placement that are referred to the practice by a candidate presented by HSDRS. I will cooperate with and make HSDRS aware of any and all progressive talks of employment or offers of employment to candidates in a timely fashion. Once I fill my position, I will furnish HSDRS with the name(s) of the person(s) hired. I am aware that there is no guarantee or warranty, implied or written, that a candidate will accept the position. All opportunities are individual and stand on their own merits. Furthermore, there is no guarantee as to how long such a placement may take. NON-DISCLOSURE AGREEMENT Whereas, In order to evaluate various potential associate candidates, the undersigned may be informed of, provided, presented and/or entrusted with various personal, business and other confidential information and documents by Henry Schein Dental Recruitment Services (hereinafter referred to as "HS NDO"), a division of Henry Schein Financial Services, LLC (HSFS), its agents, and/or representatives; and Whereas, Disclosure of said confidential information, documents, and/or the names of the parties involved may result in serious economic and other consequences to the parties involved, including their agents, representatives and HS NDO; Therefore, the undersigned party hereby agrees as follows: Except as provided in section 4. hereinafter, not to disclose or discuss any information, documents, the names of the parties or circumstances associated with any information disclosed to the undersigned by HS NDO or the party whose information is being disclosed, unless said disclosure has been authorized in writing by HS NDO. Except as provided in section 4. hereinafter, not to disclose to anyone any ideas or concepts, information, documents, contracts, or procedures given to or discussed with the undersigned by HS NDO for the purpose of considering or entering into any agreement involving an Opportunity for which HS NDO is providing consulting services. Not to make any copies, reproductions or any other records of any information or documents presented to the undersigned for the purpose of evaluating a potential Candidate including any materials, contracts or other documents entrusted to the undersigned by HS NDO for the purpose of evaluating the Candidate. Notwithstanding anything to the contrary contained herein or as previously prohibited, the undersigned shall be allowed to disclose to the undersigned 's legal, accounting, or other personal advisor and/or spouse any information disclosed to the undersigned without obtaining the previously mentioned prior written consent, providing that the undersigned acknowledges and agrees to accept personal responsibility for any damages incurred as the result of any subsequent disclosure of that information by the party to whom the undersigned has disclosed said information. To hold HS NDO, HSFS, and its agents and representatives harmless from any action taken as a result of the undersigned 's disclosure of said information, or the subsequent disclosure by any agent of the undersigned to whom said information was disclosed. To return all materials, data, contracts, documents, or other materials entrusted to the undersigned immediately upon request by HS NDO. Not to directly or indirectly contact the Candidate who is being considered, or any current or past employers or representatives of said Candidate without prior written authorization from HS NDO. The undersigned agrees and acknowledges that the agreements made herein shall continue after the closing of any legal transactions between the undersigned and the party whose information has been disclosed. Henry Schein Dental Recruitment Services will be held harmless for any misinformation provided by the Candidate or Client. In order to successfully submit this form, you must electronically sign this document. By signing this document, you accept the Non-Disclosure Agreement above. Additionally, by completing this interview and submitting this data form, you attest that all information provided is true and correct. Please add your electronic signature to this document by typing your name in the signature box below.Signature* CAPTCHA