BRISTOL SCHOOL FOR DENTAL CARE PROFESSIONALS
EXTENDED DUTY APPLICATION FORM for REGISTERED DENTAL HYGIENISTS/THERAPISTS 2016
In order to be able to enrol on the course, you must hold current GDC registration as either a Dental Hygienist or Dental Therapist.
If you are undertaking an Adaptation Period with the General Dental Council to be able to work in the UK, you must provide a reference number and certificate confirming details of the Adaptation Period. Please contact the GDC’s Registration Department (www.gdc.org.uk) for more information regarding Adaptation Periods.
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Surname/Family Name |
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First Names |
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Title Mr/Mrs/Miss |
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Name on the General Dental Council Register if different from above |
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Current UK GDC Registration Number as a Registered Dental Hygienist or Therapist |
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Year, School and Country of original training as a Hygienist/Therapist |
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Home Address |
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Postcode |
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Home Telephone |
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Mobile Telephone
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Work Telephone |
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Email Address |
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COURSE REQUIRED:
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Course |
Cost |
Session Date/s |
Tick |
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Local Anaesthesia Administration – 2 Day course (Local Infiltrations & Inferior Dental Blocks) |
£300.00 |
Friday 10th June & Friday 2nd September201609.30 – 17.00 |
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Temporary Dressings, Removal of Cement with Rotary Instruments & Recementing crowns with temporary cement |
£150.00 |
Thursday 9th June 2016 09.30 – 13.00 |
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Taking Impressions |
£100.00 |
Thursday 9th June 2016 14.00 – 16.00 |
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FOR COMPLETION BY LEAD SUPERVISING DENTIST for LOCAL ANAESTHESIA COURSE:
Role of Supervising Dentists/Hygienists/Therapists:
- Directly supervise the clinical administration of 10 LIA &/or 10 IDB by 10th December 2016
- Provide written feedback in clinical log book
- All supervising Dentists/Hygienists/Therapists must be currently registered with the GDC
‘I hereby agree to the above role, to provide clinical support to enable the applicant to complete his/her training in the administration of local anaesthetic anaesthesia.’
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Name of lead supervising dentist:
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GDC Number of lead supervising dentist:
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Practice Address:
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Signature of lead supervising dentist:
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Date:
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PAYMENT DETAILS FOR EXTENDED DUTY COURSES:
Payment:Enclose separate cheque/s per course with this application. Cheques made payable to ‘Above & Beyond Charities’. Places are offered on a first come, first serve basis. Payment will be returned if the course is oversubscribed.
Reply to:
Donna Parkin, DCP School Administrator
School for DCP Training, Bristol Dental Hospital
Lower Maudlin Street, Bristol, BS1 2LY
Tel: 0117 342 4136 Email: donna.parkin@uhbristol.nhs.uk
FOR LOCAL ANAESTHESIA ADMINISTRATION APPLICANTS:
- Do you hold a previous qualification for administering Local Infiltration Anaesthetic?
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Yes
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No go to question 2
If yes:
a) State the year and place of your LIA qualification .................................................
b) How frequently are you currently using infiltrations?
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Weekly
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Monthly
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Infrequently
- Not at all
c) How confident/competent do you feel with administering local Infiltrations?
Not confident Very confident
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- Do you hold a previous qualification for administering Inferior Dental Blocks?
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Yes
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No
If yes:
a) State the year and place of your IDB qualification .................................................
b) How frequently are you administering ID blocks?
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Weekly
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Monthly
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Infrequently
- Not at all
c) How confident/competent do you feel with administering inferior dental blocks?
Not confident Very confident
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