Local Anesthesia Registration Form
Thank you for choosing NCDHA for your Local Anesthesia certification! Please flll out this form in its entirety. Please be advised that your course instructor will send out course information to you after this form is completed and payment is submitted.
Contact Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
ADHA Number (if applicable)
*
Professional Background
Dental Hygienist License Number
*
Please upload a copy of your current Dental Hygienist License
*
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of
Please upload a copy of your current CPR certification card
*
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of
Current Practicing Office
*
Number of years actively employed in the dental hygiene industry
*
By signing below, I attest that I have been a licensed dental hygienist for at least two years
*
Course Information
Please choose the date you would like to take the clinical portion. Note if no dates are available, you can select add me to the waiting list and you will be notified when dates become available.
*
Please Select
Add me to the waiting list
Would you like to register for your complimentary Saturday one day registration?
Yes, sign me up!
No, I can't make it
Would you like to register for your complimentary Friday one day registration?
Yes, sign me up!
No, I can't make it
I want to register as a
*
Member - $900
Nonmember - $1,000
I understand that
*
If I choose the September 13 or 14 clinical date, I will not be able to begin the didactic portion of the course until August 23 and that this course requires a minimum of 8 participants registered by August 23.
Total Registration
Payment Information
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