NCDHA Local Anesthesia Registration Form

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 NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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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Please upload a copy of your current CPR certification card*

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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*

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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.*
I want to register as a*

Member - $1,000Nonmember - $1,200
I understand that*

I will not be able to begin the didactic portion of the course until February 10 and that this course requires a minimum of 7 participants registered by February 10.
Total Registration
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Local Anesthesia Registration Form

Contact Information

Professional Background

Course Information

Payment Information

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