Convention Registration Form

YOUR PERSONAL INFO

Practice name is required
First name is required
Last name is required
Phone number is required
Email is required
Address is required
City is required
State is required
Zip is required
Notes
  • Sorry, no refunds will be made.
  • Staff does not need to register with a dentist.
  • Name tags will not be mailed this year.  All attendees will need to pick up their name tag at the Convention.
UDA MEMBER DENTIST NAME ($130)
ADA is required
Full name is required
Email is required
OUT-OF-STATE ADA MEMBER DENTIST NAME ($230)
ADA is required
Full name is required
Email is required
NON-UDA/ADA DENTIST NAME ($625)
Full name is required
Email is required
SPOUSE OF DENTIST NAME ($40)
Full name is required
FULLY RETIRED DENTIST NAME ($0)
ADA is required
Full name is required
Email is required
SPOUSE OF FULLY RETIRED DENTIST NAME ($0)
Full name is required
STUDENT NAME(S) ($10)
Full name is required
STAFF DOES NOT NEED TO REGISTER WITH A DENTIST ($55)
Code is required
Full name is required
Email is required
UDA DENTAL HYGIENIST AFFILIATE MEMBER NAME ($40)
Full name is required
ID is required
Email is required
NON-UDA AFFILIATE HYGIENIST NAME ($110)
Full name is required
Email is required
Team Luncheon ($30)
Full name is required
Email is required
Alliance Luncheon ($25)
Full name is required
Email is required

Hands on workshops
Count
Cost
CPR CERTIFICATION Thursday 9:00 to 10:30 AM ($40)
Full name is required
ACLS Skills Pass Off Th AM ($150)
Full name is required

Hands on workshops
Count
Cost
CPR CERTIFICATION Thursday 2:00 to 3:30 PM ($40)
Full name is required
ACLS Skills Pass Off Th PM ($150)
Full name is required
Flap Design, Incisions, & Suturing for Periodontal Therapy ($35)
Full name is required
Modern Monolithic Injection Molded Composite Dentistry: Concepts-Materials-Instruments-Techniques Thursday ($35)
Full name is required
Local Anesthesia Technique Workshop Th PM ($35)
Full name is required
Anatomy Flashback: What You NOW Realize You Really Needed to Know! Thursday ($35)
Full name is required

Hands on workshops
Count
Cost
CPR CERTIFICATION Friday 9:00 to 10:30 AM ($40)
Full name is required
ACLS Skills Pass Off Fr AM ($150)
Full name is required
Anatomy Flashback: What You NOW Realize You Really Needed to Know! Friday ($35)
Full name is required
Restoring the Primary Molar: From Caries Detection to Pulp Therapy and MID Restorations ($50)
Full name is required
Local Anesthesia Technique Workshop Fr AM ($35)
Full name is required
From Our Side of the Chair - Workshop 1 ($35)
Full name is required

Hands on workshops
Count
Cost
CPR CERTIFICATION Friday 2:00 to 3:30 PM ($40)
Full name is required
ACLS Skills Pass Off Fr PM ($150)
Full name is required
Local Anesthesia Technique Workshop Fr PM ($35)
Full name is required
From Our Side of the Chair - Workshop 2 ($35)
Full name is required
Modern Monolithic Injection Molded Composite Dentistry: Concepts-Materials-Instruments-Techniques Friday ($35)
Full name is required
2018 Classification of Periodontal Conditions ($35)
Full name is required

Grand Total ($)

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