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
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a copy of your current CPR certification card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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
*
Clear
Course Information
You may begin the didactic portion of the course at any time after registering. 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
I want to register as a
*
Member - $1,000
Nonmember - $1,200
Total Registration
Payment Information
My Products
prev
next
( X )
USD
Description
Credit Card
Submit
Should be Empty: