Form To Request Inclusion on the CAO Locum Tenens List

• I would like to have my name, address and phone number listed with the California Association of Orthodontists (CAO) as being available as a fill-in orthodontist during the temporary absence of one of it’s members.

• I verify that I have a current valid dental license issued by the California State Board of Dental Examiners allowing me to practice dentistry within the state of California.

• I  do / do not  (circle one) have professional liability coverage. My professional liability policy is issued by:
  ____________________________________.

• I agree to inform the California Association of Orthodontists immediately if I choose to no longer be available as a temporary orthodontist.

Signature _________________________________

Date ____________

Name ____________________________________

Degree __________

Address _________________________________

________________________________________

________________________________________

Phone #_________________

Dental School _________________________

Year of Graduation ______

Orthodontic School _____________________

Year of Graduation ______

Enclosed is a listing fee of $15.00, which provides one year of listing.

Mail To: CAO 505 Beach St., Suite 130, San Francisco, CA 94133

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

Also see: