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Pre-Enrollment Information

First Name*

Last Name*

Email Address*

Address*

City*

State*

Zip Code*

Primary Phone*

Alternate Phone*

Emergency Contact*

Relationship*

Phone*


Two Character References

1. Name*

1. Relationship*

1. Phone*

2. Name*

2. Relationship*

2. Phone*

Course Information

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Referred By*

More Information About Reference


Medical Information

Medical Allergies

Allergic To Latex?*
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Medical Conditions

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Education

Highest Level of Education*

Year Graduated / Last Year Attended*


Employment

Most Recent Employer*

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Dates Employed*

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Upcoming Classes

Start Date: December 4, 2017

Monday & Wednesday AM: 9:30AM – 12:30PM

Start Date: January 5, 2018

Friday: 9:00AM – 3:30PM

Read more about…

Classroom Hours

  • Monday9am - 6pm
  • Tuesday9am - 6pm
  • Wednesday9am - 6pm
  • Thursday9am - 6pm
  • Friday9am - 6pm
  • SaturdayClosed
  • SundayClosed
Instructors

Karen Vess
Founder / Instructor
Karen brings over 37 years of experience and expertise to…
Debbie Sanders
Instructor
Debbie is an Expanded Functions Dental Assistant and became a…
Contact Info

  • 348 Southport Circle, Suite 102
  • Virginia Beach, VA 23452
  • (757) 239-0652
  • info@practicaldentalassisting.com