Application for Dental Hygiene Light Activated

Bleaching Certificate

Applicant’s Name: ____________________________________

Address: _______________________________________________ _______________________________________________________

Phone Number: ___________________________

Dental Hygiene License Number: _______________

1) Two (2) hours of didactic instruction which includes a video or demonstration of bleaching techniques and isolation.

Course Title and date: ________________________________

Location: _______________________________________

Hours: __________

Instructor: _______________________________

Instructor’s Signature: _________________________

Date: _____________

2) Upon completion of the course, the applicant must pass a written examination with a minimum score of seventy-five (75%).

Written Score: ____________

Instructors Signature: _________________________________

Date: ______________

3) The course content must include, but not limited to the subjects listed in the bleaching course requirements document available from the West Virginia Board of Dental Examiners office or on the website www.wvdentalboard.org.

A course syllabus must be submitted with the application to determine if this requirement has been satisfied.

WV Board of Dental Examiners

PO Box 1447

Crab Orchard, WV  25827

Application Fee: $25.00