Local Anesthesia Registration
8/13/2014 - 8/14/2014

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.

This four-day course will satisfy the State of Illinois expanded function training requirements to allow registered dental hygienists to administer local anesthesia under the general supervision of a licensed dentist. Dr. Stanley F. Malamed's Handbook of Local Anesthesia (4th or 5th edition) text is NOT included in the fee and must be purchased and must be independently purchased. Course dates August 13, 14, 20 & 21.

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):
City:
State:
ZipCode:
Phone (Office):
Email:
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:

Local Anesthesia (8/13/2014)

     Local Anesthesia
     Member Dentist Staff: $950.00
     Non member Dentist Staff: $1,100.00

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






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