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Dental Hygienist Request Form

Accepting Requests for Lincoln, Seward, Grand Island & Hastings, Nebraska
 
Need to cancel or amend a previous request? 
Please email: dreamteamtemps@yahoo.com 
 
Have an urgent request and are an existing client?
Text your request to: 402-202-0485

After completing this request form, you will receive a confirmation email within 1-2 business days.
 
 

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* 1. Practice Name

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* 2. Have we sent a Dental Hygiene Sub to your office before?

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* 3. Is this sub request for a new address or new location?

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* 4. Contact info  
*only complete this section if you're a new client or have a new address

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* 5. Your Name (Individual authorized to submit requests on behalf of the practice).  
*If you are not authorized on this account, please submit to your practice representative (office manager, dentist, etc.)

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* 6. Your email address

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* 7. Submit the DATES you are requesting.

Date
Date
Date
Date
Date
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Date

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* 8. Enter the HOURS of operation for your requested dates above. 
The start time is the appointment time of your first patient.  (Ex:  8am-5pm)

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* 9. Do you have any other information you would like to provide regarding this request?

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* 10. TERMS AND CONDITIONS:

Services:
Temping is a situation where the agency recruits a licensed dental hygienist to practice dental hygiene services for the Client when requested. Requested services must be within scope of practice and equipment must be supplied by Client.

Direct Placement is a situation where the Client has interest in hiring a Temp from DTT&C for a permanent position. Please contact me via email (dreamteamtemps@yahoo.com) or by phone 402.202.0485 for your paperwork to hire your temp.

Fees:
Hourly Rate for Temp: $48
Booking Fee per day: $50
Cancellation Fee per day: $50
Short Notice Cancellation Fee per day: $100
Direct Placement Fee: $500 minimum or 3.5% of the Temp's annual salary
Late fee/interest: 2.5%

Other info:
Payment to Temp is due within 14 days of service.
Client will receive 2 invoices:
1. Daily booking fee from agency for recruiting services.
2. Hourly rate from Temp for services rendered.

For questions about tax classifications of your Temp, please, contact your accountant.

Cancellations may be subject to fees and will be discussed at time of cancellation prior to applying fee to Client account.

Invoices not paid within 15 days from receipt of the invoice will be considered past-due. Past-due invoices may be charged a fee of 2.5% per month until paid to the extent allowable by Nebraska law up to 16%

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