Dental Professionals’ Guide To Chemical Dependency
Name: Title: Specialty:
City: State: ZIP: Country:
Telephone: Home ( ) Office ( )
Lic. Renewal Date: AGD Member ID:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information
above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6)
Complete the Course Evaluation below. 7) Make check payable to Penn Well Corp. For Questions Call 800-633-1681
1. Define chemical dependency.
2. Recognize the signs and symptoms of chemical dependency.
3. Be familiar with the etiology of chemical dependency.
4. Understand the diagnosis and treatment modalities for patients with chemical dependency.
5. Safely render dental treatment to patients with chemical dependency problems.
1. Were the individual course objectives met?
Objective#1: Yes No Objective#2: Yes No Objective#3: Yes No
Objective#4: Yes No Objective#5: Yes No
Please evaluate this course by responding to the follo wing statements, using a scale of Excellent = 5 to Poor = 0.
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0
4.Howwouldyouratetheobjectivesandeducationalmethods? 5 4 3 2 1 0
5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0
6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0
7. Was the overall administration of the course effective? 5 4 3 2 1 0
8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0
9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0
10. Do you feel that the references were adequate? Yes No
11. Would you participate in a similar program on a different topic? Yes No
12. If any of the continuing education questions were unclear or ambiguous, please list them.
13. Was there any subject matter you found confusing? Please describe.
14. How long did it take you to complete this course?
15. What additional continuing dental education topics would you like to see?
For IMMEDIATE results,
go to www.DentalAcademyOfCE.com to take tests online.
INS TAN T EXAM CODE 15166
Answer sheets can be faxed with credit card payment to
Payment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
If paying by credit card, please complete the
following: MC Visa AmEx Discover
Acct. Number: ______________________________
Exp. Date: _____________________
Charges on your statement will sho w up as Penn Well
If not taking online, mail completed answer sheet to
Penn Well Corp.
Attn: Dental Division,
1421 S. Sheridan Rd., Tulsa, OK, 74112
or fax to: 918-831-9804
AGD Code 157
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PAR TICIPANTS.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included
with the course. Please e-mail all questions to: email@example.com.
All questions should have only one answer. Grading of this examination is done manually. Participants will
receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be
mailed within two weeks after taking an examination.
All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE
credits. The formal continuing education program of this sponsor is accepted by the AGD for Fello wship/
Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact
their state dental boards for continuing education requirements. Penn Well is a California Provider. The
California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.
Penn Well is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association
to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours
by boards of dentistry.
Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada.
The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General
Dentistry. The formal continuing dental education programs of this program provider are accepted by the
AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance
by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from
(11/1/2015) to (10/31/2019) Provider ID# 320452
PennWell maintains records of your successful completion of any exam for a minimum of six years. Please
contact our offices for a copy of your continuing education credits report. This report, which will list all
credits earned to date, will be generated and mailed to you within five business days of receipt.
Completing a single continuing education course does not provide enough information to give the
participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of
many educational courses and clinical experience that allows the participant to develop skills and expertise.
Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
The images provided and included in this course have not been altered.
© 2017 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell
INS TAN T EXAM CODE 15166