Contact Dentist Info

Will You Be One?

Sign up to be a contact dentist for your state representative and senator…
Having contact dentists for every state legislator is vital to PDA’s advocacy efforts. They need to hear from you directly on issues impacting your profession and practice, and your patients.
Yes, I will be one!
Full Name*

First NameLast Name
E-mail*
Phone (optional)
I know who my legislators are.

Yes. Please list names below.No. Please provide address below and we will provide their names to you.
If you answered "No", please complete this information.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please click the "Submit" button below. A staff member will be in touch with the name/s of your legislators and will be able to answer questions as well.
If you answered "YES", please provide the information below.
Legislator's Name
Nature of relationship (click all that apply)

ConstituentFriendAcquaintancePractice in district
Legislator's Name
Nature of relationship (click all that apply)

ConstituentFriendAcquaintancePractice in district
Legislator's Name
Nature of relationship (click all that apply)

ConstituentFriendAcquaintancePractice in district
Legislator's Name
Nature of relationship (click all that apply)

ConstituentFriendAcquaintancePractice in district
By submitting this form, you agree to be contacted by PDA with more information related to the volunteer position as a Contact Dentist.
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Will You Be One?