MIDWINTER Registration 2022
NOTE: After completing this portion of the registration, payment must be made separately. See instructions at the end of survey.
REGISTRATION COST:
ADA Member Dentist: $250 each
ADA Member's Hyg/Staff: $75 each
Non-Member or Walk-In Dentist: $310
Non-Member's Hyg/Staff: $125 each
Dental Assisting/Hyg Student: $35
Sign in to Google to save your progress. Learn more
Email *
Dentist Name: First and Last *
Office Address (street address, city, state, zip) *
Office Phone *
Attendee Names: Provide first and last names of all staff attendees, besides dentist. If no staff will be attending, please indicate by entering NONE. *
Continental Breakfast and Lunch will be provided for all registered attendees. If any of your team members prefer a vegetarian lunch, please indicate how many vegetarian lunches are needed.
I understand that payment is due upon registration. NOTE: After completing this portion of the registration, payment must be made separately. For online payment, use our website (mbdds.org) for payment processing. A link is also provided in the MBDDS newsletters. Or you may send a check to Dr. Micah Marth, 122 43rd St., Bellingham, WA 98229. Make checks payable to MBDDS. Please direct any questions to mbdds@mbdds.org. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy