AzAGD For the Love of the Dental Team
This registration form is for AGD Doctor Members (active, in good standing) to complete to register up to two dental team members for the March webinar series.

Doctor members do not need to be in attendance.
Dental team members will receive a zoom link to participate virtually from their respective dental offices.
Arizona AGD will deliver/post-mail supplies 1 week prior to each webinar event.

Internal use: https://forms.gle/3fbxRhY5mmWXmULd9
Doctor's First and Last Name *
Doctor AGD ID# *
Doctor's Email Address *
Doctor Office Mailing Address *
Name of Malpractice Insurance Company *
State of Dental License *
Dental License Number *
NPI Number *
Each AGD member doctor is able to register up to two dental team members to participate in the 3-part series.
Dental Team Member #1 Name *
Dental Team Member #1 Email *
Dental Team Member #1 Phone Number (that can receive text for any last minute changes/tech issues) *
Dental Team Member #1 Role *
Required
Dental Team #1 Member Will Attend the Following Courses (check that apply). *
Required
Dental Team Member #2 Name *
Dental Team Member #2 Email (type N/A if you are not sending a second member) *
Dental Team Member #2 Phone Number (that can receive text for any last minute changes/tech issues) *
Dental Team Member #2 Role *
Required
Dental Team #2 Member Will Attend the Following Courses *
Required
This 3-part series is FREE to 2 dental team members who work for an AGD member dentist. However, we have limited space due to limited resources. If your dental team members fail to participate in the course, they have taken the space and resources from someone else who could have benefited from the experience. Therefore, we will charge you $25 per course when a dental team member registers but does not show up on the day of the event. Please enter the following information in case this takes place. If your dental team member(s) shows up, we will not charge your credit card.
Credit Card Type: Visa, Mastercard, Discover *
Name on the Credit Card *
Credit Card Number *
Credit Card Expiration Date *
Credit Card Security Code *
Please initial your understanding of the Cancellation Policy: I understand that I may cancel a dental team member's participation without penalty as long as I inform AzAGD of the cancellation AND return the provided course materials at least 7 days BEFORE the course. I understand that I may substitute a dental team member with another dental team member without penalty up until 2 days BEFORE the course. *
Please initial your understanding: I understand that my dental team member(s) benefit most from having access to teleconferencing (laptop with video and audio) AND a dental office/operatory for all three courses. The provisional course will require the use of a hand piece. The x-ray course will require an x-ray unit, a live human model, and rinns/digital sensor. And the SDF course will require teeth mounted in a cup/stone and high suction vacuum. I will do my best to provide the necessary resources for my dental team. *
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