Table Clinician Application

Dentists must use their specific ADA or CDS membership number. Dentists who do not use their own number will not be considered for a Table Clinic at the Midwinter Meeting.

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 (select one)	--------- Communication Endodontics Forensics General Implants Lasers Myofunctional Therapy Occlusion Office Management Orthodontics OSHA Oral Pathology Pathology Patient Management Pediatric Dentistry Periodontics Prevention Prosthodontics Restorative Dentistry Sleep Apnea TMJ Other Enter other subject here.

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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	--------- Local Chicago Dental Society Associate Chicago Dental Society American Dental Association
Member ID
Category*	--------- Private practice Federal dental service Full-time dental faculty Full-time graduate dental student Undergraduate dental student Practicing dental hygenist (RDH) Practicing dental assistant Dental laboratory technician
CDA
CDT

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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	--------- Local Chicago Dental Society Associate Chicago Dental Society American Dental Association
Member ID
Category	--------- Private practice Federal dental service Full-time dental faculty Full-time graduate dental student Undergraduate dental student Practicing dental hygenist (RDH) Practicing dental assistant Dental laboratory technician
CDA
CDT

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Need a kodak carousel slide project and table top screen
Need an LCD display
Number of outlets
Other needs
Preferred Times	Thursday February 24, 2011 - AM Thursday February 24, 2011 - PM Friday February 25, 2011 - AM Friday February 25, 2011 - PM Both days

What is the word in this picture?:*

Submit