ADTC Course Waitlist Signup

1
CE Course & Date Selection* This field is required.Please select the course from the dropdown that you'd like to be added to the waitlist for.
Please Select Course from list
Please Select Course from list
Oct. 28-30 2022 - Fundamentals of Dentistry
Nov. 11-13 2022 - CBCT Imaging of the Head & Thoracic Radiology
Nov. 19-20 2022 - Technician Workshop
Dec. 9-11 2022 - Fundamentals of Dentistry
Jan. 20-22 2023 - Oral Surgery 1+2 / Radiology
Feb. 3-5 2023 - Fundamentals of Dentistry
Feb. 18-19 2023 - Technician Workshop
Mar. 4-5 2023 - Advanced Oral Surgery 3
Apr. 14-16 2023 - Fundamentals of Dentistry
May. 19-21 2023 - Endodontics 1 / Radiology
Jun. 2-4 2023 - Fundamentals of Dentistry
Select Class from Drop-down menu
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Contact Name* This field is required.Who should we contact in the event a registration spot opens?
Dr.
Dr.
Ms.
Mr.
Mrs.
Prefix
First Name
Last Name
3
Number of Attendees* This field is required.
Please enter the number of people interested in signing up
4
Clinic / Hospital Name* This field is required.Please enter your clinic or hospital name.
Clinic / Hospital Name
5
Email Address* This field is required.Please enter a personal email address and not a general hospital mailbox. All course correspondences will be sent here.
example@example.com
Confirm Email
6
Phone Number* This field is required.If there is a question about your registration what is the best contact number to reach you directly?
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Additional CommentsAnything else we should know or can help with?
Should be Empty: