Coronal Polishing & Pit/Fissure Sealants Registration

Please complete the form below, choose the activities that you wish to attend,
and select your method of payment at the bottom of the page.
Fields in bold red are required for successful registration.

Continental breakfast & lunch are provided

Attendee Prefix:
Attendee First Name:
Attendee Middle Name:
Attendee Last Name:
Attendee Suffix:
Supervising Dentist
(for dental assistants and non-member hygienists):
Address Line 1 (Office):
Address Line 2 (Office):
Phone (Office):
ADA (or ISDS) Number (numbers only):
Comments: (250 characters max)
Please use the box below to provide the names of any additional registrants/guests or list any dietary restrictions:

Event Activities:

Coronal Polishing Pit/Fissure Sealants (9/13/2014)

     Coronal Polishing & Pit/Fissure Sealants
     Member Dentist Staff: $450.00
     Non-Member Dentist Staff: $800.00

Please select your method of payment
(a confirmation page will be displayed on the next screen including the total price):

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