PDM REGISTRATION FORM
PDA/ADA
Member Dentists
Select Courses
Non-Member Dentists Hygienists, Assistants,
Non-Licensed Staff
and Guests
By 3/29 After 3/29
By 3/29
After 3/29
By 3/29
After 3/29
Saturday, April 25 – 8:00 a.m
Medical Marijuana (2 hours of CE) m $95 m $135
m $195
m $275
m $95
m $135
Saturday April 25 – 8:00 a.m
Act 124 Opioids (2 hours of CE) m $75 m $105
m $175
m $245
m $75
m $105
Saturday, April 25 – 10:30 a.m
Act 31 Child Abuse Recognition (2 hours of CE) m $60 m $85
m $160
m $225
m $60
m $85
Saturday, April 25 – 12:30 p.m
Tickets for Lunch NOTE: lunch is not included
with any programs or CE m $38 m $38
m $38
m $38
m $38
m $38
Saturday, April 25 – 1:30 p.m.
Your First 10 Years of Practice m $0 m $0
m $0
m $0
Saturday, April 25 – 1:45 p.m.
PDA Legislative Update & Business Meeting m $0
m $0
Saturday, April 25 – 2:00 p.m.
Local Anesthetic & Nitrous Oxide Administration
(2 hours of CE) m $75 m $105
Saturday, April 25 – 6:00 p.m.
Council of Presidents’ Meeting - open to presidents
and presidents-elect of district & local dental societies m $0 Not Available
Not Available
Not Available
Not Available
m $0
m $245
Not Available Not Available
Not Available
Not Available
m $175
m $0 m $0
m $75 m $105
Total Due $_____________________________________________
Method of Payment
Please make check payable to: PDA and mail with completed form
to P.O. Box 3341, Harrisburg, PA 17105 or fax your registration to
(717) 232-7169 or register online at www.padental.org/PDM
m Check m MasterCard m Visa m American Express m Discover
CARD NUMBER
EXP. DATE
Registrations accepted until April 13, 2020. Cancellations must be received
in writing by April 15, 2020. No refunds will be issued for registrations
cancelled after April 15. Cancellations can be faxed to (717) 232-7169
or emailed to [email protected].
Questions?
Contact Rebecca Von Nieda at (717) 234-5941, ext. 117
or [email protected].
SIGNATURE
PRINT NAME AS IT APPEARS ON THE CARD
N OVEM BER/DECEM BER 2019 | P EN N SYLVAN IA DEN TAL JOURNAL
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