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Meeting Brochure - West Coast Dental Association

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Join Us in St. PeteHilton Bayfront<strong>West</strong> <strong>Coast</strong>District<strong>Dental</strong><strong>Association</strong>PresidentialCocktail ReceptionMuseum of Fine ArtsNew DentistReception88thAnnual <strong>Meeting</strong>St. PetersburgHilton BayfrontFebruary 5, 2010A Taste For WineFeatured Speakers:Dr. Gerard Chiche u Katherine EitelAngie Stone u Lisa Harper-Mallonee


88th Annual <strong>Meeting</strong> • St. Petersburg Hilton BayfrontFebruary 5, 2010Dr. Steve KristProgram ChairmanDear Colleagues,The program committee of the <strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong> <strong>Association</strong> has been charged to providethe finest day of continuing education that you could find anywhere in the country. We believewe have answered this challenge. On February 5, 2010 Gerard Chiche, D.D.S. will highlight ourwinter meeting. We are proud to be back at the St. Petersburg Hilton Bayfront for a day full ofexcellent lecturing, wonderful fellowship with other members of our profession, and an opportunityto share a powerful team building experience with staff. Mark your calendar and plan to spenda rewarding day with us on February 5th.Rediscover Downtown St. PeteAll Over Again...• Thursday, February 4 th you are invited to thePresidential Cocktail Reception held at thebreath taking newly remodeled Museum of Fine Arts.Mingle with friends and tour the museum.• Top notch speakers at a reasonable price. The entire dentalteam will have a good experience and learn valuable career enhancing information.• A Taste for Wine is the spot for our annual New Dentist reception. Graduates of2000 or after are invited for fine wine and networking.• Downtown Music Series – Downtown St. Petersburg is home to the ‘First FridayCelebration’! Join the street party on Central Avenue between 2 nd and 3 rd Streetwith vendors and live music 5:30 p.m. – 10:00 p.m.• Restaurants and Pubs – one of your harder decisions on Friday night will be whereto eat dinner. Walking distance from the host hotel are some of the best restaurantsand pubs in the Tampa Bay area. Central Avenue Oyster Bar, Café Alma, CevicheTapas, Red Mesa Cafe, Pacific Wave and The Garden are just a few of the programcommittee’s favorites. Visit www.discoverdowntown.com for a complete listing.• Nightlife – make your way to Ceviche’s basement where live music will be sure tomake you move or make your way to Vintage Ultra Lounge for a night of fun. Don’tforget to see who will be playing at Jannus Landing Courtyard and Progress EnergyCenter for the Arts - Mahaffey Theater.• Shopping, Museums and Galleries – if you haven’t been to Downtown St. Petersburglately make sure to schedule an additional day to enjoy the museums, antique shopsand boutiques. Visit www.discoverdowntown.com for a complete listing.Visit www.discoverdowntown.com for additionalinformation on things to do, maps and parking.


HOTEL AND MEETING LOCATION INFORMATIONSt. Petersburg Hilton Bayfront is located at 333 First Street South, St. Petersburg, FL33701 in the waterfront district of downtown St. Petersburg, Florida across fromProgress Energy Park and The Mahaffey Theater. Walking distance to downtownSt. Petersburg, The Pier, Baywalk, Salvador Dali Museum and a variety of restaurantsand nightlife. Convenient access to I-275, St. Petersburg Clearwater Airport is 15minutes away and Tampa International Airport is 25 minutes away.All lectures, Exhibition Hall and registration will be located in Lobby II and III, on thefirst floor of the hotel.DIRECTIONSAccess door to door directions on www.googlemaps.com, www.mapquest.com, etc.From Tampa: take I-275 south to Exit 22: I-175. The exit will turn into 5 th Avenuesouth. Follow 5 th Avenue south to First Avenue south. Follow 5 th Avenue south to 1 stStreet south, turn left. Hilton is 2 blocks on the left.From South FL: take I-75 toward Tampa. At Exit 228, take ramp right for I-275toward St. Petersburg. Merge onto I-175 via Exit 22 toward Tropicana Field. Turnslight left onto 5 th Avenue south. Turn left onto 1 st Street Southeast. Hilton is 2 blockson the left.PARKINGThere are several parking garages surrounding the hotel, two of the closest are1 block north at 2 nd Street and 2 nd Avenue, both are $5.00 a day. St. PetersburgHilton Bayfront parking is available for $5.00, over 5 hours $12.00 a day.Visit www.discoverdowntown.com for an interactive map of the downtown areaincluding parking garages.Drive time to St. Petersburg from:Tampa ................... 25 minClearwater ................ 20 minPinellas Beaches. ........... 10 minBradenton ................ 20 minSarasota ................. 40 minLakeland . . . . . . . . . . . . . . . . . .40 minNaples .................. 120 minHotel ReservationWhen making your reservation at the St. Petersburg Hilton Bayfront, be sure to mention the <strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong><strong>Association</strong> Annual <strong>Meeting</strong> in order to receive the group rate of $159.00. Reservations can be made by calling1-800-944-5500 or online at www.wcdental.org.<strong>Meeting</strong> Facts• Registration: Pre-register before January 25, 2010 to avoid late fees. Register via mail, fax (813) 931-1851 oron-line at www.wcdental.org.• Badges & Tickets: All pre-registered attendees will receive badges and tickets via mail prior to the meeting date,allowing you to visit the exhibitors and enjoy morning coffee without having to stand in line. Lanyards and on-siteprograms will be easily accessible.• Exhibit Hall and On-site Registration: Opens at 8:00 a.m. in Lobby II & III.• Handouts: Download your course handouts at www.wcdental.org, click on the ‘Professional’ area, then click onthe ‘2010 Annual <strong>Meeting</strong>’ in the left column, scroll down to ‘Handouts’. Handouts will be available 2 weeks priorto the meeting.• Discounts Available: All public health or government dental personnel or dental educators receive a 25% discounton seminar fees.• Late Fee: It is the policy of the <strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong> <strong>Association</strong> to charge an additional $20.00 fee after thepre-registration date 2 weeks prior to the meeting, January 25, 2010.• Refund and Cancellation Policy: All requests for refunds or cancellations must be made in writing to the WCDDAprior to the pre-registration deadline. A cancellation/processing fee of 15% will be charged. No refunds will begiven if cancellation is received after the pre-registration deadline. No refunds will be given on site. Lunch tickets arenonrefundable.• Questions concerning the meeting or registration contact WCDDA at (813) 931-3018 or email Melissa atMelissa@wcdental.org.Register online at www.wcdental.org2


88th Annual <strong>Meeting</strong> • St. Petersburg Hilton Bayfront • February 5, 2010Course DescriptionsRecipes for PredictableAnterior EstheticsSeminar A9:00 a.m. – 4:30 p.m.(6 CEUs)Includes Lunch Buffet TicketThis presentation will discuss the keyareas for efficient esthetic diagnosisGerard J. Chiche, D.D.S.and smile design. These key pointswill be formulated into a simple andsystematic step-by-step approach to resolve esthetic problemsand achieve predictable esthetic results and improvedlaboratory support. This presentation will also offer anoutline of prosthetic and adhesive techniques in terms ofarmamentarium and products as well as practical techniquesfor tooth preparations, bonding sequence, and cementationfor all-ceramic crowns and porcelain veneers. Topics to becovered include:ESTHETIC DIAGNOSIS and TREATMENT PLANNING1. Key Factors for Treatment Planning of AnteriorRestorations: A Methodical Treatment SequenceApplicable to Major and Minor AnteriorRestorations.2. Step-by-step Esthetic Analysis for maximumpredictability. How to identify the red flag areasprior to treatment and how to establish a Prognosisfor Predictable Esthetic Outcome.3. Effective Rules of Comprehensive smile design withcomplex case. Strategies for managing Elective andComprehensive Treatment.ESTHETIC QUALITY CONTROL: KEYS to SUCCESS1. Porcelain Veneers: System Selection, Tips onOptimum Preparation, Shade Control and Maskingstrategies. Step-by-step Bonding Technique andsystematic Cement Selection.2. Establishing a Comfort Zone with the differentsystems of All-Ceramic Crowns and Fixed PartialDentures. Selection Criteria, Cement Selection andupdate on bonding research, Step-by-step BondingTechnique.3. Communication with the <strong>Dental</strong> Laboratory: ShadeMatching, Shading effects, step-by-step Planning forOptimum Arrangement and Composition, SpecialEffects and Smile Design Variations.4. Esthetic-Restorative and Periodontal – RestorativeComplications.D, A3 Register online at www.wcdental.orgLioness LeadershipSeminar B9:00 a.m. – noon (3 CEUs)Lions are born leaders. Cubs are bornwith instincts to hunt, propagate, lead,and thrive... they just don’t know it.The primary goal of mature lionessesis to awaken those instincts to ensurethe success of the pride. Like lions,Katherine Eitelyou already have the instinctive abilityto lead, and lead powerfully, from where ever you are inlife... most of us just don’t know it, or trust it, yet.It’s in you. Leadership has nothing to do with owning abusiness, the number of people you manage, how old youare, how long you’ve been in the business or how muchyou make. It has everything to do with your state of mindand the skill sets you master. This course will helpyou access the leader within, communicate andthink like a leader, connect vision to action andinspire those around you to do the same.A Practical Approachto Improving Oral Carein the Dependent AdultPopulationSeminar C9:00 a.m. – 11:00 a.m.(2 CEUs)This course addresses oral care issues Angie Stone, RDH, BSfacing dependent adults, with a focuson nursing home residents and their primary care givers,namely nursing assistants and nurses. Education regardingsimple advanced treatment modalities isIf yousign up forboth C & Dboxed lunchis included!delivered. This information will get attendeesenergized about this population. Learnabout the Adopt a Nursing Initiative. Comefeel the excitement!D, A, HRecall, Recare, Who Really CaresAngie Stone, RDH, BSSeminar D 11:30 a.m. – 12:30 p.m. (1 CEU)Some refer to return patient hygiene visits the “Recall”appointment, while others refer to the appointment as the“Recare” appointment. Over the last few years there has beendiscussion regarding what is the best terminology. Whatever itis called, it is important to understand that there is a “system”that drives these return visits. This course addresses the who,what, where and when of running an effective recall system.D, H, S


88th Annual <strong>Meeting</strong> • St. Petersburg Hilton Bayfront • February 5, 2010CPR Re-certificateSeminar E 9:00 a.m.Seminar F 1:00 p.m.This course will include training incardiopulmonary resuscitation (CPR)at the basic support level, includingone-person, two-person and childtechniques, review heart disease,heart attack, airway obstruction,Michael Coxrespiratory arrest and cardiacarrest. The performance of CPR and maneuvers to relieveobstructed airways will be taught. There will also be asegment on the use of Automatic External Defibrillator(AED). This course will meet your CPR needs as requiredby the State of Florida.D, H, L, A, SLunch BuffetNoon – 1:00 p.m.Downtown St. Pete offers many walking distance optionsfor lunch, visit www.discoverdowntown.com for a detailedlist. If you prefer to stay at the hotel for lunch you will enjoya comfortable setting and a delicious variety.Table Clinic PresentationNoon – 1:30 p.m.Earn up to 2 FREE CEUs for viewing table clinicpresentations prepared by dental assisting and dentalhygiene students in the <strong>West</strong> <strong>Coast</strong> district.Fattening of America—What DOES Dentistryhave to do with it?Seminar G9:00 a.m. – noon (3 CEUs)The population is growing… and soare our waistlines! The dental visitisn’t “just about the mouth”—it’s about Lisa F. Harper-Mallonee,the whole patient! The updatedBSDH, MPH, RD, LDfood pyramid—how can we relatethis information to our patients? Sugar intake, portioncontrol—encouraging healthy habits—what does dentistryhave to do with the obesity crisis? Ongoing research andemerging information regarding diet and nutrition as itrelates to oral health will be discussed.Course Outline: At the conclusion of this course you willbe able to:• Understand the interrelationship between obesityand oral health.• Relate the importance of diet to dental patientsduring oral health care appointments.• Encourage healthier food choices.• Work with nutrition professionals asmultidisciplinary team members in patientmanagement.• Manage nutritional issues either by direct patientguidance or appropriate referral.D, H, L, A, SNew Dentist ReceptionFebruary 5th5:00 p.m. - 7:00 p.m.A Taste For Wine241 Central Ave, St. Petersburg(3 blocks walking distance from the St. Pete Hilton Bayfront)R.S.V.P. by January 25th(800) 260-5277 or wc.dental@gte.netJoin your new dentist colleagues forfine wine and great conversation!<strong>Dental</strong> school graduates from 2000 and later are welcome!Register online at www.wcdental.org4


88th Annual <strong>Meeting</strong> • St. Petersburg Hilton Bayfront • February 5, 2010Have Them at HelloKatherine EitelSeminar H 1:30 p.m. – 4:30 p.m. (3 CEUs)Throw out those scripts! You can be better and stillbe YOU! In this presentation, Katherine Eitel, one thenation’s leading experts in patient communications, willshow you how to throw out the scripts and tap into your owninstinctive greatness to be better than ever! By following afew simple steps, everyone can improve their results on thephone and their value to the practice. Katherine will giveyou four simple yet innovative steps that will increase yourproductivity tomorrow with new patient phone calls. Also,improve your success with price shoppers, insurance-drivenpatients, emergencies, “cleaning only” patients, pendingtreatment and hygiene reminder calls as well as confirmationcalls and ways to cut your cancellations in half!Don’t Market Your Practice... until you and your teamhave taken this course! If you currently promote (or plan topromote) your practice in any media such as yellow pages,direct mail, newspaper, radio, television, retail signage orsimply through a targeted internal PR campaign, this coursewill dramatically improve your success and ROI with thesetelephone calls. Designed for doctors and the entire team,this course will change the way you view those mediagenerated,or internally-generated, phone calls for whichyou are paying so much money!D, H, L, A, SBrilliant HyDuction, My Dear HygienistAngie Stone, RDH, BSSeminar I 1:00 p.m. – 4:00 p.m. (3 CEUs)Many deductions have been drawn to improve the worldof dental hygiene for patients and hygienists alike. JoinAngie as she takes attendees on a journey through theworld of these HyDuctions. Topics include PerioDuction(Periodontal Deductions), InstraDuction (InstrumentDeductions), MIDuction (Minimal Intervention Deductions),ProDuctions (Productivity Deductions) and many more!D, HHealthy Mouth, Healthy Body—Healthy PracticeLisa F. Harper-Mallonee, BSDH, MPH, RD, LDSeminar J 1:30 p.m. – 4:30 p.m. (3 CEUs)As dental professionals, we are in a unique position toprovide our patients with the highest degree of preventivehealthcare. Thus, we need to be knowledgeable aboutthe multifaceted world of medicine and how it affects ourpatient’s overall health and well-being. It is imperative thatwe embrace the basic concepts of cariology and periodontaldisease progression. These basic constructs coupled withongoing research and emerging information regardingdiet and nutrition as it relates to oral health can be appliedduring patient care. Not only will it help us keep ourpatients healthier..but our practice will benefit as well!This course provides information that is both practicaland scientifically based. At the conclusion of the course,participants will be able to:• Discuss diet and nutrition as it relates to propermaintenance of oral health and overall health.• Discuss scientific evidence presented in the literatureregarding nutrition and oral health.• Identify patients that require basic nutritionalcounseling in the dental practice.• Identify oral sequelae, which may be related to poordietary intake.• Relate the importance of diet to dental patients duringoral health care appointments.• Manage dental nutrition issues either by direct patientguidance or appropriate referral.• Work with nutrition professionals as multidisciplinaryteam members in patient management.D, H, A, SAudience KeyD - Dentist/<strong>Dental</strong> Student, H - Hygienist/Hygiene Student,L - Lab Tech, A - <strong>Dental</strong> Assistant/Assisting Student, S - Office StaffEnhancing Nature Through Science: Recognize, Rejuvenate and RestoreAmy Nieves, RDHSeminar K 1:30 p.m. – 3:30 p.m. (2 CEUs)All dental team members are key players in caries therapy. Learn ways to remineralize and protect enamelwith current remineralization technologies. MI (Minimal Intervention) dentistry is the modern “medical”approach to the management of decay. Three key elements of the MI philosophy of Recognizing,Rejuvenating, and Restoring will be presented. This course provides an in depth discussion on enamelmaturation and the caries balance theory. It highlights the trend for diagnostic saliva testing which aidsin assessing the risk factors of caries in your patient population. In addition, this course will discuss thedifferent working mechanisms of glass ionomer as a surface protectant, topical fluoride, ACP, CPP-ACP,and Calcium Sodium Phosphosilicate and how these innovative materials can influence your patient’soral health. You will come away with a full understanding of caries as an infectious, multi-factorial andmicrobiologic disease and learn to develop and implement new and effective caries preventive carestrategies.D, H, A5 Register online at www.wcdental.orgFREESEMINARSponsoredbyGC America Inc.


88th Annual <strong>Meeting</strong> • St. Petersburg Hilton Bayfront • February 5, 2010Program SpeakersDr. Gerard J. Chiche is the Helmer Professor and Chairman of the Prosthodontics Department at Louisiana StateUniversity School of Dentistry. He has given numerous programs nationally and internationally and holds membershipin the American College of Dentists, the American Academy of Esthetic Dentistry, the American Academy of FixedProsthodontics, the American Academy of Restorative Dentistry and the Omicron Kappa Upsilon <strong>Dental</strong> Honor Society.He is a Past President of the American Academy of Esthetic Dentistry and is also, respectively with Alain Pinault andHitoshi Aoshima the author of the textbooks: Esthetics of Anterior Fixed Restorations, and Smile Design - A guide forClinician, Ceramist and Patient both published by Quintessence Pub. Co. He serves as adjunct faculty at the PankeyInstitute, he is the recipient of the 2003 LSU Alumni Award, the 2003 Educational Community Achievement Award ofthe Seattle Study Club for best dental educator of the year and the 2007 Distinguished Lecturer Award of the GreaterNew York Academy of Prosthodontics.Katherine Eitel, creator of The Lioness Principle, is an international speaker, author, and experiencedcommunications coach specializing in non-scripted, extraordinary communications for dental/discretionary healthcareand service-based business creating greater profitability and personal joy. With over 25 years experience as chairside assistant, treatment coordinator, marketing director, and small business/practice management coach, Katherine’srevolutionary communications training programs have helped hundreds of practices and small businesses throw outtheir old, tired scripts and access instinctive greatness improving marketing results, organizational systems, clientservice and verbal skills, and bottom line. She’s a nationally-renowned speaker, recipient of the coveted “Spotlighton-Speaking”award from the Speaking Consulting Network as well as a published author in the new book, PowerfulPractice. Katherine is a frequent contributor to most major industry publications.Angie Stone, RDH, BS, has been in the dental profession for over 25 years. She has held virtually each positionwithin the dental office including dental assistant, front office and dental hygienist. She has spent time teaching bothdental assisting and dental hygiene. Currently she:• Provides clinical hygiene services in private practice and nursing home environments• Is Editor in Chief of Hygiene Tribune• Provides corporate consulting services to dental product companiesMichael Cox is retired from active fire service. He has served as a CPR Instructor and Instructor/Trainer since 1980,including six years an instructor at the Florida State Fire College in Ocala. He also worked in the Prevention Divisionin Tampa for multiple counties. Currently Michael is employed by Florida State Fire Marshal.Lisa F. Harper-Mallonee, BSDH, MPH, RD, LD is a Registered Dietitian and Associate Professor at Texas A&MHealth Science Center Baylor College of Dentistry. In addition to her academic role at BCD, Ms. Mallonee coordinatesa dental clinic rotation for the BUMC and UT Southwestern dietetic interns. She also serves as a nutrition consultant tothe Cooper Wellness Program in Dallas, TX.Amy Nieves, RDH, is a Mentor of The Year (2003) and Award of Excellence (2004) winner. She graduated in 1999from Middlesex County College in Edison, NJ. She presently is the Southern MI Specialist for GC America, Inc.In 1999 she started what was to become the most widely read dental hygiene internet community. Her websitewww.amyrdh.com is a starting point for students and graduated dental hygienists alike.From 2000-2007 she was a regular columnist for the peer review journal Contemporary Oral Hygiene with hermonthly column “Hygiene Solutions.” In 2004 she co-authored the book The Purple Guide: Developing Your Clinical<strong>Dental</strong> Hygiene Career with another Lister Shirley Gutkowski.Register online at www.wcdental.org6


<strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong> <strong>Association</strong>9720 North Armenia Avenue, Suite FTampa, FL 33612(813) 931-3018 Fax (813) 931-1851E-mail: wc.dental@gte.netPRESORTEDSTANDARDU.S.POSTAGEPAIDTAMPA, FLPERMIT NO 3239Presidential Cocktail PartyR.S.V.P. by January 22 nd(800) 260-5277 or wc.dental@gte.netTours of the museum will be hosted through the event.Dr. and Mrs. Rudolph T. Liddellrequest the pleasure of your companyat the Presidential Cocktail Partyof the<strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong> <strong>Association</strong>’s88th Annual <strong>Meeting</strong>Thursday, the fourth of Februarytwo thousand and tenseven until nine o’clock in the eveningMuseum of Fine Arts – Marley Room & Gardens255 Beach Drive NESt. Petersburg, Florida 33607Register & DownloadYour Handouts online@www.wcdental.org


St. Pete Hilton Bayfront • Registration Form • February 5, 2010Eighty-Eighth Annual <strong>Meeting</strong> of the <strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong> <strong>Association</strong>Seminar Time Title Dentist Fee Staff FeeA 9:00 am - 4:30 pm Recipes for Predictable Anterior Esthetics (Includes Lunch) $195.00 $110.00B 9:00 am - Noon Lioness Leadership $45.00 $45.00C 9:00 am - 11:00 am A Practical Approach to Improving Oral Care in the Dependent Adult Population $20.00 $20.00D 11:30 am - 12:30 pm Recall, Recare, Who Really Cares $20.00 $20.00C & D 9:00 am - 12:30 pm Both Courses (Includes Boxed Lunch) $45.00 $45.00E 9:00 am CPR Recertification $35.00 $35.00F 1:00 pm CPR Recertification $35.00 $35.00Seminar Title Dentist Fee Staff FeesGA & B 9:009:00amam–-4:30Noonpm <strong>Dental</strong>FatteningMedicine,of AmericaThe Future- WhatIn NowDOES Dentistry have to do with it? $45.00 $45.00H 1:30 pm - 4:30 pmIncludesHaveLunchThem at Hello$175.00$45.00 $45.00I A 9:00 1:00 a.m.- pm noon - 4:00 pm <strong>Dental</strong> Brilliant Medicine, HyDuction, The Future My Dear In Now Hygienist /morning session only $100.00 $45.00 $45.00J B 1:30 1:30 p.m. pm –- 4:30 pm <strong>Dental</strong> Healthy Medicine, Mouth, The Healthy Future Body In Now - Healthy /afternoon Practice session only $100.00 $45.00 $45.00K C & F 9:00 1:30 a.m. pm –- 3:30 4:30 pm p.m. Bambi Enhancing vs. Godzilla Nature and Through Emotional Science: Intelligence Recognize, Rejuvenate and Restore FREE FREEL Noon Includes Lunch Lunch Buffet $30.00 $75.00 $30.00 $75.00C 9:00 7:00 a.m. pm –- noon 9:00 pm Bambi Presidential vs. Godzilla Cocktail Party (Thursday February 4th) # of Attendees _______ $30.00 $30.00D 9:00 5:00 a.m. pm - 7:00 pm CPR New Re-certification Dentist Reception (Friday February 5th) # of Attendees _______ $35.00 $35.00E noon Luncheon $27.00 $27.00F 1:30 p.m. – 4:30Thep.m.PriceEmotionalof EachIntelligenceCourse will increase by $20.00 after January 25, 2010!$30.00 $30.00Complete Registration Policies are located on Page 2.G 1:30 p.m. CPR Re-certification $35.00 $35.00Registration instructions: Print primary dentist info. below, indicate seminar letter and and fee fee in in boxes boxes below, below, total total across, across, total total down down with with staff staff registration,registration, include payment. include Fax payment. or mail registration Fax or mail to registration WCDDA central to WCDDA office. central You may office. also register on-line at www.wcdental.org.All dentists must register as dentists – please print clearlycheck category that applies belowDentist Name:__________________________________________________ WCDDA Member FDA Mbr ADA Mbr Non ADA Mbr - $250.00ADA Number: _________________________________________________Address: _________________________________________________________________ City: _________________ State: ________ Zip: _________________Email: ______________________________________________________ Telephone #: __________________________________________Dentist NameCircle1. DMD or DDSSeminar Fee Seminar Fee Seminar Fee Total2. DMD or DDSStaff RegistrationStaff Name/job titleJob title keyHygienist – H Office Staff - SAssistant – A Lab Tech – LHygiene Student – HSAssisting Student – AS1.Seminar Fee Seminar Fee Seminar Fee Total2.3.4.5.6.7.Total dentist fee plus total staff fee: _________Payment Information: make check payable to WCDDA Visa MasterCardCard Number: ______________________________________Exp Date: ___________ Signature: __________________<strong>West</strong> <strong>Coast</strong> District <strong>Dental</strong> <strong>Association</strong>9720 N Armenia Ave. #F – Tampa, FL 33612Registration Questions (813) 931-3018 Fax (813) 931-1851www.wcdental.org

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