Form To Request a CAO Locum Tenens List

• The California Association of Orthodontists (CAO) provides a list of practitioners who have indicated a willingness to act as a locum tenens orthodontist during the temporary absence of the owner of an orthodontic practice. CAO has not screened these individuals and has not verified their qualifications or ability to perform the work required in an orthodontic office.

• It is the responsibility of each orthodontist to verify the credentials of the proposed locum tenens as well as satisfy the professional liability requirements for their office(s) through their own professional liability insurance carrier.

• I have read the above two paragraphs and understand that CAO assumes no liability in representing their credentials. I understand that I am responsible for negotiating my own individual working arrangements with any individual(s) that I may contact from the list. I agree that CAO assumes no responsibility in the establishment of a working relationship with the names on the list.

Print Name______________________________

Signature_______________________________

Date_____________

Please send the locum tenens list to:

Name ___________________________________

Address _________________________________

________________________________________

________________________________________

Phone # _________________________________

Mail to: CAO 1323 Columbus Ave., Suite 301, San Francisco CA 94133    Or Fax: 415-441-5683

For any questions regarding the locum tenens program, please contact Jeff Milde at info@caortho.org or 415 441-4697.

Also see:

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