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Online Application
Your Information
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Office Information
Office Name:
Address Line 1:
Address Line 2:
City: State: Zip:
Office Phone:
Office Fax:
Office Email:
Contact person(s):
Please list Associates if applicable:
Additional Offices:
Number of Hygienists:
Number of Assistants:
Office Schedule
Hours: Lunch:
Additional Information
Average number of patients seen daily:
Hygiene appointment length:
Is there a morning huddle? Yes No
Is there on site parking? Yes No
Are uniforms provided? Yes No
Is there a staff lounge? Yes No
When will temporary employees receive compensation?
Please list all specialty services that your office employs or recommends.
In order to proceed, you must agree with the following rules:
Throughout this Agreement, the parties shall be referred to as follows: Dental office or Doctors shall be referred to as ‘Client’. Dental FillIns, Inc. shall be referred to as ‘DFI’. Please read and fully understand the following before submitting:

1. A representative of DFI shall visit offices prior to assignments whenever possible. DFI reserves the right to refuse to provide DFI staff to Client at any time for any problems that arise in connection with temporary staff provided to Client, including but not limited to non-OSHA standards, mistreatment of DFI temporary staff by client, delinquent accounts.

2. Client shall provide proper eye protection and practice OSHA universal precautions for infection control.

3. Each shift worked by temporary staff provided to Client shall commence fifteen (15) minutes before the first scheduled patient, and temporary staff is to be paid by Client for his or her services from the commencement of his or her shift. All DFI temporary staff scheduled more than a 6 hour shift will be scheduled with a thirty (30) minute break. All DFI temporary staff scheduled more than an 8 hour shift will be scheduled with a sixty (60) minute break. DFI temporary staff will not receive payment for these scheduled breaks.

4. Client shall report all problems with DFI temporary staff to DFI immediately. Prompt action will be taken to attempt to resolve the situation.

5. In addition to the placement fee to be paid to DFI pursuant to Section 6 below, DFI temporary staff is to be paid directly by Client at the end of the scheduled assignment (but not less than weekly if the assignment is scheduled in advance to last for more than one (1) week) unless previous arrangements have been made with DFI at least twenty-four (24) hours prior to assignment. DFI shall have no obligation to compensate temporary staff in this regard. DFI temporary staff rate shall be agreed upon at confirmation of assignment between DFI and client. Weekly assignments are to be paid to DFI temporary staff at the end of the week. If Client cancels an assignment without twenty-four (24) hours notice, Client is responsible to pay DFI temporary staff twenty-five (25) percent of scheduled wages.

6. DFI is to be paid by Client the appropriate placement fee set forth on the attached fee schedule within ten (10) days of receiving an invoice for temporary staffing. Payment for permanent placement fees will be as set forth in the Permanent Placement Addendum; DFI may pursue any and all legal or equitable remedies available against Client if such permanent placement fee is not paid to DFI within thirty (30) days of the first day of such permanent placement. All rates are subject to change with thirty (30) days notice. DFI assignments cancelled by Client without twenty-four (24) hours notice are subject to the aforementioned temporary placement fee, payable to DFI.

7. Client and its owners, employees, agents, officers and directors agree not to employ, engage or contract directly or indirectly with any DFI temporary staff for a period of twelve (12) months from the last assignment date. A permanent placement fee will be charged to a Client who employs, engages or contracts directly or indirectly with a DFI temporary staff within twelve (12) months of last assignment date. In such an instance, if the Permanent Placement Addendum is not attached hereto and executed by DFI and Client, the permanent placement fee shall be equal to the applicable rate on the then-existing DFI permanent placement fee schedule, payable to DFI within ten (10) days of such a hire.

8. Client shall keep all DFI temporary staff information confidential and not disclose such information to any third parties.

9. Client agrees to hold DFI harmless from any and all liability for any loss, claim, liability or damage occurring during the DFI temporary staff assignment. Client shall hold DFI harmless for alleged negligence or malpractice of DFI temporary staff. Client shall provide at its sole cost and expense malpractice coverage for DFI staff while providing services to Client. Each of Client and DFI agrees to be bound by this Agreement.

10. Either party may terminate this Agreement for any reason, with or without cause, by providing thirty (30) days written notice to the other, subject to the continuing obligations of Sections 3, 5, 6, 7, 8 and 9 hereof.

11. Each of DFI and Client agree to be bound by the terms of this Agreement.