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Request Shadowing Hours

Thank you for your interest in learning with Hudec Dental! The following documents are required to be signed and uploaded to your application: HIPAA Policy and Cell Phone Policy.

A signed copy of the Hepatitus B Acknowledgement and a copy of your Hepatitus B Vaccination record is also required to be emailed to recruiting@hudecdental.com in order for your request form to be considered complete.

Important Note: The signer must be 18 years of age or older. If the participant is under 18 years of age, a parent or legal guardian is required to sign all applicable documents.

HIPAA Policy
Cell Phone Policy
Hep B Acknowledgement

Shadowing Request Form

"*" indicates required fields

Name*
Please enter a number from 0 to 500.
Please use the following format: mm/dd/yyyy
Requested Organization Location(s)*
Select between 1 and 3 choices.
Disclaimer: We will do our best to accommodate your requested organization location(s); however, placement at a preferred location cannot be guaranteed.
Accepted file types: pdf, Max. file size: 300 MB.
Please upload your signed copy of our HIPAA Policy as a PDF document.
Accepted file types: pdf, Max. file size: 300 MB.
Please upload your signed copy of our Cell Phone Policy as a PDF document.
Acknowledgment*