• First Name
• Last Name
• Address 1
• Address 2
• City
• State
• Zip
• Home Phone
  (including Area Code)
• Work Phone
  (including Area Code)
• Best time to call?
  Daytime Evening
• Email

Continuing Education Areas of Interest:

• Clinical Interest
  Local Anesthesia Nitrous Oxide Sedation Radiology for Assistants 1 DH Restorative Endorsement Perioscope, New DH Instruments, Ultrasonics Rubber Dam Impressions Topical Anesthetic
• Community Oral Health
  Diabetes Nutrition Treating AIDS Patients Fluoride
• Professional Development
  Dental Hygiene Education Rural and Community Health Mental Health & Oral Needs Top Drugs Used & Impact on Practice Oral-Systemic Health Diagnostic Devices for Oral Cancer Screening
• Suggestions
• Are you a licensed dental hygienist?
  Yes No
• If so, in what states?
• Are you a dental assistant?
  Yes No
• If so, do you have an Expanded Functions certificate?
  Yes No
• Please write any specific questions you have here:
• Please let us know how you heard about us: Internet Search ADHA Educational Conference Friend Other