WCMID World Congress in Minimally Invasive Dentistry Registration Form

WCMID Registration Form

Please fill out this form to register for the WCMID 9th Annual Conference!

Name:*required field	Title or Position:
Affiliation:	Dental School Attended:
Degree:	Mailing Address:
City:	State & Zip:
Business Phone:*required field	Fax:*required field
Home Phone:*required field	Email:*required field
Website:	Name on Conference Name Tag:
Do you require CE credits? Yes No

Type of Attendee:
General Member
Lifetime Member	Dental Spouse/Guest
Dental Educator	Board Member
Advisory Board Member	Founding Member

Minimally Invasive Technology & Procedures Practiced:
Magnification Loupes	Microscope
Cerec	Sealants
Air Abrasion	Diagnodent
Implants(instead of 3-unit bridge)	Difoti Diagnosis Tool
Lasers	Invisalign Orthodontics
Caries Risk Assessment	Caries Detection Dye
Digital X-ray	Sleep Apnea
Soft Tissue Management	Periscopy
Tooth Whitening	Low Level Laser
Periodontal Risk Assessment	Biomimetic Materials
Inlays/Onlays Inlays/Onlays


Form of Payment: Check Credit Card

WCMID 133 Fernwood Drive, Suite 400 Moraga, CA 94556
Phone: 800-973-8003 925-388-0070	Fax: 925-631-9525