EmailMeForm
Dent-Ed Solutions, LLC Registration Form
Please fill out this form before Paying Online.
Title
*
DDS
DMD
RDH
RDA
CDA
EFDA
CDA, RDA
Other - Please specify Title
Name
*
First
Last
Address 1
*
Address 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Email
*
Phone
*
###
-
###
-
####
Professional License #
AGD Member
*
Yes
No
AGD Member #
Cell Phone
###
-
###
-
####
Please provide in case of emergency or changes
Person paying for this course
*
Self
Other - Type name of person paying for the course(s)
Additional registrants
If registering more than one person, please type each persons name and title
Would you like to receive email notifications of upcoming courses?
*
Yes
No
We are committed to keeping your e-mail address confidential. We do not sell, rent, or lease our subscription lists to third parties, and we will not provide your personal information to any third party individual, government agency, or company at any time.
Important Information
* Note: You will not be completely registered unless you pay after filling out this registration form. Below is some helpful information.
1. Once you click on the Register button below, it will take you to the Dent-Ed Solutions, LLC Courses Selection web page.
2. From that web page you will select the course or courses by clicking the Add to Cart button to the right of the course.
3. Only one course could be added to the Shopping Cart at a time.
4. If you will be selecting more than one course then you will need to click on the Continue Shopping button from the Shopping Cart.
5. From within the Shopping Cart, if you're going to pay with a Credit Card, then you would click on the button that says Check Out
6. Only click on the button that says Check out with PayPal if you have a PayPal account.