Arizona Dentist Membership Application

(* = Required Fields)
 
Information:
*Full Name (First Middle Last)
Phonetic Pronunciation (To help us pronounce your name when we give referrals)
ADA Member Number
*Arizona Dental License
Date of Birth (mm/dd/yyyy)
Gender  M  F
Spouse Name
Email (We do not share/publish member email addresses)

 
 
 
 
Preferred Mailing Address:
*This Address Is  Home    Office #1    Office #2
*Address
*City    *State    *Zip
*Phone    Fax
Website

 
 
 
 
Secondary Address:
This Address Is  Home    Office #1    Office #2
Address
City    State    Zip
Phone    Fax
Website

 
 
 
 
Alternate Address:
This Address Is  Home    Office #1    Office #2
Address
City    State    Zip
Phone    Fax
Website

 
 
 
 
Education:
Please indicate ADA-reconignized specialty you are limited to
  General Practitioner
  Endodontics
  Pediatric
  Public Health
   Periodontics
  Prosthodontics
  Oral Pathology
  Oral Surgery
   Oral Radiology
  Orthodontics

*Dental School
*Graduation Date   Degree Earned
Internship/Military   From   To
Post Graduate Training   From   To
Other Training

 
 
 
 
Membership Agreement:
I HEREBY APPLY for membership in the American Dental Association, Arizona Dental Association and my local dental society and resolve to abide by the Constitution and Bylaws, Principles of Ethics and Code of Professional Conduct and the Peer Review Program of each organization, if elected for membership.

I CERTIFY THAT all statements made by me in this application are complete, true and honest. I understand and agree that if any statement is found to be false or omitted, this application may be rejected solely for that reason. I also understand and agree that in the event such false statement(s) or omission(s) does not become known to the Dental Society until after I have been elected, I understand my membership may be terminated immediately on the basis of incomplete or false information. For the purposes of this paragraph, I understand that a material misstatement or omission shall mean, one which is "significant in relation to the questions asked to which the false statement or to which the omission was made."

I FURTHER AFREE that I will recognize the authorized officers of my local dental society and said Association as the proper and sole authorities to interpret all areas of professional conduct and interpretations.

UPON BECOMING A MEMBER of the local dental society, Arizona Dental Association and the American Dental Association, I hereby waive the right to hold this society, the Association or any member thereof, responsible for any damage in case of disciplinary action involving me, after a hearing in accordance with the Bylaws of this society, the Arizona Dental Association and the American Dental Association.

*I have read and understand the above membership agreement.


 
I was referred/recruited to membership by Dr.

 
 
 
 
Referral Information:
The Arizona Dental Association provides approximately 500 patient referrals each week. So that we can provide the most up-to-date information about your practice, please check each service your dental office provides.
  Bleaching/Whitening
  Cancer Patients
(Radiation & Chemo Therapy)
  Dental Phobias
  Dentures
  Emergencies
  Evening Hours
  Financing, Tx
   Friday Hours
  General Anesthesia
  Hospital Privileges
  Implants
  Infant Patients
  IV Sedations/
       Anesthesia
  Lasers
   Latex Allergies
  Saturday Hours
  Senior Discounts
  Sign Language
  Nitrous Oxide
  Nursing Home Calls
  Oral Conscious
       Sedation
   Pediatric Dentistry
  Special Needs
  TMJ/TMD
  Wheelchair Bound
       Patients

  Foreign Languages:


 
 
 
 
Volunteering:
Please indicate the coucils/committes on which you have interest in serving.
  Ethics/Peer Review
  Membership
  Volunteer Opportunities
  Communications
   Continuing Education
  Donated Dental Services
  Dental Health
  New Dentist Activities
   Foundation Activites
  Legislation
  Speaker's Bureau
  Fundraising

 
 
 


Note: As a member, you can login to the "Members Area" of this website to update this information if it changes.