North Dakota Smiles For Life Training Completion Form

 

I hereby state that I have completed and satisfactorily passed the Smiles for Life Fluoride Varnish Training Module 6.

Name:                   

Designation:                
(ex: physician; physician’s assistant; nurse practitioner; registered nurse; licensed practical nurse; advanced practice nurse)

Affiliation or Clinic:     

Telephone Number:        

E-mail address:          

Date: