Nitrous Oxide Monitoring and Administration 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.

This Course is designed to meet the requirements of the Illinois Dental Practice Act & the Rules Administering the Dental Practice Act. This course includes both lecture & clinical exposure. A certificate of completion will be issued upon course completion. Prerequisite - current CPR/BLS certificate, 1000 hours as a dental assistant required

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:

Nitrous Oxide Monitoring and Administration (10/8/2014)

     Member Dentist Staff: $275.00
     Non-Member Dentist Staff: $500.00

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

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