Radiographic Techniques Registration
11/1/2014

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 8-hour course is designed for dental assistants who already possess fundamental skills in dental radiography. The course will be structured such that the participant, upon completion, should reveal a refinement of existing radiographic skills, as well as the ability to satisfactorily demonstrate newly acquired ones.

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:

Radiographic (11/1/2014)

     Radiographic
     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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