Dental Hygiene Applicant Shadowing Form
*If shadowing at more than one office, you may make multiple copies of this form. 40+ total shadowing hours are recommended.
Applicant Name: ____________________________________________________________
Address: _______________________________________________________________
SHADOWING VERIFICATION
The applicant named above has completed ____________ hours of observation in this office on _____________________________________________________ date(s).
List the type of procedures observed:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Comments (optional):
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Dental Hygienist(s) Observed:
___________________________________ _______________________________________
Printed Name Signature
__________________________________ _______________________________________
Printed Name Signature
__________________________________ _______________________________________
Printed Name Signature
Office Address: ________________________________________________________
________________________________________________________
Office Telephone: _____________________________
Please return this completed form to the Admissions Office at the Central Georgia Technical College campus of your choice:
North Campus: 3300 Macon Tech Drive, Macon, GA 31206 or FAX: 478-757-3454
South Campus: 80 Cohen Walker Drive, Warner Robins, GA 31088 or FAX: 478-988-6947