Supervising Dentist Application Form - College of Dental Surgeons of Alberta

Thank you for your interest in participating in the pilot program for the Supportive Pathway to NDEB Certification in Alberta. Please complete the following application to help us assess your eligibility and suitability for this role.

General Information

CDSA Permit Number(Required)

Your CDSA Permit Number can be found on your Practice Permit, in your Members' Portal profile, or by searching your name in the Dentist Directory

Clinical Facility Information

Facility Name(Required)

Professional Background

Thank you for considering to be part of the Supervising Dentist program, but you are not eligible as you must hold a practice permit with the CDSA as a General Dentist.

Thank you for considering to be part of the Supervising Dentist program, but you are not eligible as you must have practiced dentistry for a minimum of five (5) years.

On average, how many hours per week do you practice at your clinical facility?(Required)

If yes, please provide details.

Clinical Facility & Community Overview

If you selected other, please explain

Conflict of Interest

If yes, please provide details

Supervisory Experience

If yes, please describe your experience

Program-Specific Commitment

Thank you for considering to be part of the Supervising Dentist program, but you are not eligible as you must be available to attend the Orientation Session on Oct. 3 & 4 in Edmonton, AB.

Please share why you would like to participate and any additional information to support your application .(Required)