Review of Radiation Health & Safety Registration Form

Dental Assistant Services
1306 Highway 33, Suite 3A
Farmingdale, NJ 07727
732-919-1816

Contact InformationFull Name:    Phone number:    Type:

Address:    Phone number:    Type:

City:    State:    Zip Code:    Email:

Last four digits of Social Security Number:

Do you currently have a dental x-ray license in NJ?

If you answered yes to the last question, when did you obtain your license?

Course InformationCourse Title: Cost of Course:

Important Information This is not a live course. By completing this registration form you are purchasing a self-study course manual designed to help you pass DANB's

RHS

exam for the purpose of obtaining a CDA

certificate. If you are trying to obtain a dental x-ray license you should register for the NJ State Radiology course instead.

If you've already passed the RHS

exam (as most NJ dental assistants will in order to obtain a dental x-ray license) your passing score is valid for five years. In other words, if you can meet all of the other requirements to become a CDA

certificant in less than five years total you should not need to retake the RHS exam. Click here for further information about who should purchase this course.

Please note that as with the other program courses we offer, the purchase of this course entitles you to take a live practice test in our office for free.

Payment InformationPayment in full is required along with this registration form. Please call us at 732-919-1816 for current rates when filling out the cost in the above section.

Legal NoticeBy checking the box below I am indicating that I have read and agree to the copyright notice. Note: This check box must be marked or you will not be permitted to purchase this course.

I agree and consent

InstructionsAfter filling out this form, please print it out. Sign and date the form below and mail it to the address at the top of the page, along with your payment made out to Dental Assistant Services. This registration form must be filled out completely. Course manuals are typically mailed out in 1-2 weeks. If you need to receive a copy sooner, please call our office at 732-919-1816. We may be able to make arrangements to allow you to pick up a copy in person.

Signature: ________________________________________

Date: ____________________