dallas_county_dental_society

Dallas County Dental Society

ADA#	Social Security #
Name (List how you want it to appear in the roster)
Last	First	Middle (or initial)
Nickname

General
Gender: Male Female	Birth Date	Spouse Name
Ethnic Origin American Indian Asian African American Caucasian Hispanic Other
Email	Website

Military Service
Branch	Date Service Began	Release Date
Do you wish your name included on mailing labels? Sell Name Public Referrals (average 15 a day)
Are you incorporated? Yes No	Business name if different than your own:

Primary Mailing Address:

Office One
Address	Suite Number
City	State	Zip Code
Telephone #	Facsimile #

Office Two
Address	Suite Number
City	State	Zip Code
Telephone #	Facsimile #

Office Three
Address	Suite Number
City	State	Zip Code
Telephone #	Facsimile #

Home
Address	Apt. #
City	State	Zip Code
Telephone Number (only if you want published in Roster)

Education
Dental School	Graduation Year	Degree
Graduate School	Graduation Year	Degree
Specialty Certificate	Specialty
License Number	State
License Number	State

Specialty
Dental Public Health Oral & Maxillofacial Surgery Orthodontics Prosthodontics Endodontics	Oral & Maxillofacial Pathology Pediatric General Oral & Maxillofacial Radiology Periodontics

Type of Practice
Sole Owner Full-time (over 30 hours a week) Full-time practice / Part-time faculty Armed Forces Hospital Staff Dentist	Other Occupation Associate Part-time (under 30 hours a week) Part-time faculty / Part-time practice Federal Services	Graduate Student / Resident No longer in practice Faculty State / Local Government Other Non-Dental Student

Foreign Language

Affiliations
Are you related to another dentist? Yes No	If yes, who?
Do you know an elected official well enough to call him/her? Yes No
If so, who?	Position

Dallas County Dental Society Member Referral Form

Name

Primary Mailing Address:

Office One
Address	Suite Number
City	State	Zip Code
Telephone #	Facsimile #

Office Two
Address	Suite Number
City	State	Zip Code
Telephone #	Facsimile #

Office Three
Address	Suite Number
City	State	Zip Code
Telephone #	Facsimile #

These are services requested most often by the public. Please check which of the following services that is offered by your office.
Air Abrasion Bleaching/Whitening Bonding Bus Line Close By Children CHIP Conscious Sedation Cosmetic Dentistry Crown & Bridge Partials Dentures Digital X-Rays Emergencies Evening Hours General Anesthesia Halitosis Headphones	Homebound Treatment Hospital Privileges Hypnotism Implant Procedures Intra Oral Camera IV Sedation Ultrasonic Cleaning Laser Restoration Laser Whitening Lasers Lingual Braces Medicaid Medically Compromised Medicare Mentally Handicapped Nitrous Oxide	Nursing Homes On-Site Lab Open Fridays Open Saturdays Payment Plans Physically Handicapped Portable Equipment Relaxation Methods Restorative Dentistry Root Canals Sealants Senior Citizens Discount Sliding Fee Scale TMJ Workman's Comp Wheelchair Access
Other Services:

Dallas County Dental Society

Name (List how you want it to appear in the roster)

General

Military Service

Primary Mailing Address: Home Office

Office One

Office Two

Office Three

Home

Education

Specialty

Type of Practice

Foreign Language

Affiliations

Dallas County Dental Society Member Referral Form

Name

Primary Mailing Address: Home Office

Office One

Office Two

Office Three

These are services requested most often by the public. Please check which of the following services that is offered by your office.

Other Services:

Primary Mailing Address:

Primary Mailing Address: