Annual Session

2024 DSDS Annual Session Registration Form

Complete this information even if the doctor is not attending:

Doctor's Name:
Doctor's ADA Number:
Doctor's Address:
City:
State:
Zipcode:
Email: (For reg. confirmation)
Phone:
Fax:
Home or Cell Phone: (For emergency purposes)
	Doctor is attending the meeting.

OTHER PERSONS ATTENDING:

Name:
Position:
Membership:

Name:
Position:
Membership:

Name:
Position:
Membership:

Name:
Position:
Membership:

Name:
Position:
Membership:

Name:
Position:
Membership:

Name:
Position:
Membership:

Name:
Position:
Membership:

REGISTRATION FEE: (Prior to May 7th)

DSDS/ADA Member ($315.00 per person)
Non-ADA Member ($415.00 per person)
Staff/Student/Spouse ($190.00 per person)
Residents ($0.00 per person)

Thursday, May 13
Annual Business Session and President's Dinner FOR MEMBERS ONLY

Chase Center Christina Ballroom
Complimentary (Pre-registration required no later than May 7, 2021)

Yes, I will attend the Thursday Annual Session Dinner

Doctor

TOTAL REGISTRATION $0

Refund Policy: All requests for refunds or cancellations must be received by May 1, 2024. No refunds will be given after that time. Each registration cancellation/refund will incur a $35 administrative fee. Registration funds are not transferable.

Thursday, May 13 Annual Business Session and President's Dinner FOR MEMBERS ONLY

Thursday, May 13
Annual Business Session and President's Dinner FOR MEMBERS ONLY