Boise Student Resources

Student Information

Legal Name

Preferred Name

Birth Date

Address

City

US States

Zip

Home Phone

Cell Phone

Email

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Emergency Contact

Relationship

Phone

Personal Reference: (friend or family member not living with you)

Phone

If patient is a minor, who is legally responsible? Please list the name, complete address and phone numbers of the responsible party.

How did you hear about us?

Social Media
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Family/Friend
Past ATS Student

If a past ATS student referred you, who may we thank?

Dental History

Fill out the online form below or print form here

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Patient Name

Date of Birth

Email

Are your teeth sensitive to:

Are your teeth sensitive to:

Heat

Cold

Sweets

Pressure

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Does food catch between your teeth

Do your gums bleed when brushing

Have you noticed any gum swelling around teeth

Do you have an unpleasant taste/odor in your mouth

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Problems of the Jaw:

Problems of the Jaw:

Clicking

Pain (joints, ear, side of face)

Difficulty opening/closing

Difficulty chewing

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Do you avoid any part of the mouth while brushing

Have you had a reaction to a local anesthetic

Are you dissatisfied with your teeth and their appearance

If so, please specify:

Are you concerned about the finances required to return your teeth to excellent dental health

Do you use any tobacco products

Have you ever had any teeth removed

How long have they been missing?

Do you feel you will eventually wear artificial dentures

Do you have any dental fears

Do you have any present dental concerns

Why did you leave your last dentist

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When was your last dental exam

Do you have any general health problems

If so, please specify:

Have you had surgery

If so, please specify:

Are you currently under physician’s care

Reason:

Medications:

Have you/are you taking oral bisphosphonates?

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To the best of your knowledge...

To the best of your knowledge, are/have you ever been afflicted with:

Heart Ailment

If so, please specify:

Diabetes

Rheumatic Fever

Epilepsy

Artificial joints

High Blood Pressure

Respiratory Disease

Hepatitis

HIV positive

Prolonged bleeding

Healing Complications

Allergies To any Drugs

If so, please specify:

If needed, Which Pharmacy do you prefer?

Are you pregnant?

Checking this box signifies e-signature of this document. *

Dental Fundamentals Registration Form

Fill out the online form below or print form here

Fields marked with an * are required

First Name *

Last Name *

Email *

ASSIST TO SUCCEED BOISE REGISTRATION FORM - DENTAL FUNDAMENTALS The tuition for Assist to Succeed dental assisting program is $4995.00 ($1000 discount for the first 7 students) and includes all of the following: ♦ Textbook: “Modern Dental Assisting”, Bird/Robinson 12th Ed (2018); Elsevier Publishing ♦ Syllabus: “Concepts in Dental Assisting”, ATS Partners LLC, Edition 3.2 (2016); ATS Partners, LLC Publishing ♦ All training, CPR, visual aids, materials and dental supplies used throughout the course ♦ Use of all dental equipment and instrumentation with actual “hands on” training during the course of study ♦ Training in ALL aspects of General Dental assisting, including dental specialties ♦ All training is done by dental professionals in an actual practicing dental office, not just in a classroom STUDENT RESPONSIBILITIES INCLUDE: ♦ Students are required to bring their own paper and pencils and purchase one pair of solid colored scrubs to be worn to every class. ♦ Students are required to attend all 10 weeks of class totaling 80 classroom/hands on hours. ♦ Students must pass all exams and in class requirements with 85% or higher grade to receive their dental assisting fundamentals certificate and letter of recommendation from the directors. Tuition for Assist to Succeed may be paid using one of the following 2 payment options: $4995.00 paid in full by cash, cashier check, or major credit card; or $3995 w/$1000 Discount (see above) $4995.00 paid with Care Credit Loan or Mountain America Credit Union loan, on approved credit; or $3995 w/$1000 Discount (see above) REFUND AND CANCELLATION POLICIES A cancellation fee of $170 will be assessed if the class is dropped by the second week. There will be no refunds offered after the third week of class. Rented textbooks must be returned undamaged and in good condition. For books that are written in or not returned, students will be charged $125.

Assist to Succeed Boise Registration Form - Dental Fundamentals

The tuition for Assist to Succeed dental assisting program is $5995.00 ($1000 tuition scholarship for the first 7 students) and includes all of the following:

♦ Textbook: “Modern Dental Assisting”, Bird/Robinson 12th Ed (2018); Elsevier Publishing

♦ Syllabus: “Concepts in Dental Assisting”, ATS Partners LLC, Edition 3.2 (2016); ATS Partners, LLC Publishing

♦ All training and visual aids, materials and dental supplies used throughout the course

♦ Use of all dental equipment and instrumentation with actual “hands on” training during the course of study

♦ Training in ALL aspects of General Dental assisting, including dental specialties

♦ Idaho State Certification for Dental Assisting Fundamentals

♦ All training is done by dental professionals in an actual practicing dental office, not just in a classroom

♦ Free seat at any future Dental Assisting Expanded Functions course we may offer

Student Responsibilities include:

♦ Students are required to bring their own paper and pencils and purchase one pair of solid colored scrubs to be worn to every class.

♦ Students are required to attend all 11 weeks of class totaling 88 classroom/hands on hours.

♦ Students must pass all exams and in class requirements with 85% or higher grade to receive their dental assisting fundamentals certificate and letter of recommendation from the directors.

Tuition for Assist to Succeed may be paid using one of the following 2 payment options:

$5995.00 paid in full by cash, personal loan, cashier check, or major credit card; or $4995 w/$1000 Scholarship (see above)
$5995.00 paid with Care Credit Loan or DL Evans Bank loan, on approved credit; or $4995 w/$1000 Scholarship (see above)

Refund, Cancellation and Module Make-up Policies

A cancellation fee of $300 will be assessed if the class is dropped by the second week.
There will be no refunds offered after the second week of class.
Rented textbooks must be returned undamaged and in good condition. For books that are written in or not returned, students will be charged $150.
A make-up fee of $125 will be applied per module if a student misses more than 1 teaching module per term.

Mark the box next to one of the following payment options: *

$5995.00 Payment in full with cash, personal loan, cashier check, or credit card; or $4995 w/$1000 Scholarship (see above)
$5995.00 Payment with Care Credit or DL Evans Bank; or $4995 w/$1000 Scholarship (see above)

I have chosen one of the payment options above and have read and understood all regulations and restrictions associated with my payment option. I understand that Assist to Succeed Dental Assisting School is registered with the State Board of Education in accordance with Section 33-2403, Idaho Code. I also understand that the State Board of Education has not accredited or endorsed any course of study being offered by Assist to Succeed Dental Assisting School, and that these courses may not be accepted for transfer into any Idaho public postsecondary institution.

Today's Date *

Checking this box signifies e-signature of this document. *

Student Information

Dental History

Dental Fundamentals Registration Form

Assist to Succeed Boise Registration Form - Dental Fundamentals

Student Responsibilities include:

Tuition for Assist to Succeed may be paid using one of the following 2 payment options:

Refund, Cancellation and Module Make-up Policies

Location Information