Chicago Dental Society

Midwinter Meeting

Midwinter Meeting

Table Clinician Application

Fields marked with an asterisk (*) are required.

Name of school, hospital, study club, etc. (if presenting with a group)
Title of Table Clinic* (43 character limit)
Briefly describe your Table Clinic
Subject (check one)	Endodontics Implantology Infection Control Myofunctional Therapy Occlusion (TMJ) Practice Management Oral Pathology Oral Surgery Orthodontics Pain Control Patient Management Pediatric Dentistry Periodontics Prevention Prosthodontics Restorative Dentistry General

Clinician 1

Name*
Address*
City*
State*
Zip*
Daytime Phone*
E-mail*
Have you ever presented at the Midwinter Meeting before?
I am a member of
Member ID
Category
CDA
CDT

Clinician 2

Name
Address
City
State
Zip
Daytime Phone
E-mail
Have you ever presented at the Midwinter Meeting before?
I am a member of
Member ID
Category
CDA
CDT

Need a kodak carousel slide project and table top screen
Need an LCD display
Number of outlets
Other needs
Preferred Times	Thursday February 26, 2009 Friday February 27, 2009 Both days

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Copyright — Thursday, 20-Nov-2008 04:40:17 CST Chicago Dental Society