Heartland Dental | Hygiene Blaze Fall 2023Yello Enterprise

Personal Information

First Name

Preferred Name

Last Name

Personal Email Address (Gmail, Yahoo, etc.)

Please Provide a Valid Phone Number✓ Valid phone number

Mailing Address

Dental Institution - Hygiene

Hygiene School Graduation Year

Graduation Month

OLD First Choice City & State After Graduation

OLD If you selected 'Other', please type it here ...

What is your current experience with dental lasers?

If you have more than one year of laser experience, please enter the name and date of the course taken previously.

Why are you interested in becoming laser certified?

How did you hear about this Hygiene Blaze laser training?

Please share how you spend your time outside of school, either in work, extracurricular or volunteer activities you have participated in. Give an example in a couple paragraphs how your involvement in one specific activity has aided in your personal and/or leadership development in the dental field.

At Heartland Dental, hygienists are providers. They advocate for their patients' lifetime care. Tell us in a few paragraphs about a time when you advocated for your patient(s) or when you have helped others in your life.

On a scale of 1-5, what is your familiarity with Heartland Dental? (1=No Knowledge, 5=Very Knowledgeable)

Would you be interested in interviewing for a hygiene opportunity within Heartland Dental?

LASER Media Release

Laser Certification: A Heartland Dental Education Event - Media Release Form

Use or Disclosure of Patient Photographic, Video and Testimonials Authorization Form

I authorize Heartland Dental at the Laser Certification Event program in Columbia, SC to use and disclose for educational and/or marketing purposes my first name, photographic and/or video images of me, and/or testimonials that I have provided regarding the Practice (collectively referred to as “My Media”). I also authorize any vendor providing marketing services to the Practice, including Heartland Dental, LLC, to use My Media in marketing and educational materials/services for the Practice and for other dental offices. I understand that the use/disclosure (or redisclosure) of My Media means that it may no longer be protected by HIPAA privacy regulations.

The following are some of the types of locations in which My Media may be used:

- Websites and other digital services
- Social networking and social media platforms
- Presentations to healthcare professionals, patients, stakeholders, and the general public
- Brochures, direct mail, publications, and other marketing materials
The following personal details will not be disclosed:
- My middle or last name
- My address
- My date of birth (age may be used ex. “37 years old”)
I understand that My Media may be subject to redisclosure, including by third-party sites that may link to marketing materials without first having secured permission. I understand that the Practice and its vendors have no control over, and are not liable for, redisclosures.
I have a right to revoke this authorization by providing written notice to the Practice in person or by registered mail. Revocation affects future disclosures only and cannot apply retroactively to disclosures of My Media that have already occurred.
This authorization is voluntary, and I may refuse to sign it. Refusal to sign will not affect my eligibility for treatment, benefits or enrollment, or payment for or coverage of services.
This media release supersedes any previously signed media release and is valid for ten (10) years from the date signed.
I release the Practice and its third-party marketing vendors, including Heartland Dental, LLC, from any and all liability arising out of the use of My Media.
I understand that I have a right to (and will be given) a copy of this authorization after it is signed.

I authorize use of my photo, first name and or testimonials

Heartland Marketing Disclaimer

Effective Date: March 31, 2017

Heartland Dental, LLC (the “Company”) respects the privacy of visitors to our web site, www.heartland.com. While offering its website users the advantages and convenience of web-based technologies, the Company also strives to employ practices so that information collected about prospective affiliates and visitors is used conscientiously and appropriately. Before accessing or using any part of the www.heartland.com website, you should read carefully the following Statement in detail.

This Privacy Policy Statement outlines the use of personally identifiable information collected on the website. This privacy notice does not encompass other websites referenced by the Company in print, online, or in e-mail. Our website may contain links to enable you to visit other websites easily. Other websites you visit – including those linked from the Company website – may have their own privacy policies or no policy at all. Other websites (such as those administered by third parties, including but not limited to careers-heartlanddental.icims.com) might use personal information differently than our policy permits.

Generally, the information collected through the website is information used to help the Company better serve its customers, prospective affiliates and visitors. It is Company policy not to disclose your personal information to unaffiliated third parties except as required or permitted by law.

Visitors: Information is collected for Company marketing purposes about pages that visitors browse.

Prospective affiliates: The Company collects personally identifiable information about affiliates who provide their information on web pages that are specifically designed to collect such information, including but not limited to contact and dental practice information. The Company collects information for Company marketing purposes about pages that prospective affiliates browse.

A "cookie" is a packet of information that a web server sends to a user's computer to identify that specific user the next time he or she visits the site. A cookie is used in website system administration to keep track of movement of an individual user from one screen to another.

The Company’s web server automatically collects information from your computer and navigation patterns when you visit its site, including your Internet Protocol (IP) address, the computer's operating system, the type of browser you use, and the specific web pages visited during your connection. The Company may also track data such as the total number of visits to our website and the number of visitors to each page of its website.

The Company may use this information, in aggregate form, for system maintenance and to better understand how its visitors use its website and services so that it can make them better. The Company may also share statistical or demographic information in aggregate form with third parties for marketing or research purposes. This aggregate data will not contain any information that personally identifies you.

The information collected is used to improve the content of the Company’s web site, enhance the value of its products, and communicate with prospective affiliates and visitors. The Company, its leaders, and its affiliates have access to website visitor information for purposes of communicating with affiliates and furthering the mission of the organization. Any and all information provided, produced or collected on this website by prospective affiliates and visitors may be used by the Company for Company marketing purposes.

The Company's website is intended for adults. The Company does not knowingly collect personal information from children under the age of 13. If the Company obtains knowledge that it has personally identifiable information about a child under 13 in retrievable form in its files, the Company will delete that information from our existing files.

The Company uses state-of-the-art technology to keep any information you provide as secure as possible, and have reasonable security measures in place at its physical facilities and on its web server to protect against the loss, misuse, or alteration of information collected from prospective affiliates and visitors. Requests to review security information may be sent using the contact information below.

The Company also has in place privacy protection control contractual obligations with its vendors designed so that personal data is protected from unauthorized access or disclosure. All Company employees must abide by the Company's Privacy Policy. Only authorized personnel are permitted to have access to personally-identifiable data about website visitors, and that access is limited to what is reasonably needed to perform duties and responsibilities. Employees who violate our privacy policies are subject to disciplinary action, up to and including termination.

Periodically the Company may use collected information for new, unanticipated uses not previously disclosed in its privacy notice. When its information collection and dissemination practices change, such policy changes will be posted on www.heartland.com.

To contact the Company with regard to this policy or its subject matter, please email or write us at:

Heartland Dental, LLC
Attn: Web Manager
1200 Network Centre Drive
Effingham, IL 62401

media@heartland.com

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