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Registration Information
Registration Information
Section-by-Section Instructions
 Primary Registrant Registration materials for the entire office will be sent to the
How t
o Register
Online
primary registrant’s address. All registrants must answer the three questions at the end of this section.
If you need to list more than four registrants from your office, please photocopy the registration form and
use the photocopies as continuation sheets. If using a continuation sheet, mark the box at the top left
corner of the form, enter the primary registrant’s name in section , and proceed directly to section .

specialty Please check one box only to indicate the doctor’s specialty.

registration category & fees Please note that ODC has many different
registration categories. Check the list carefully to be sure you are paying the correct fee. Note that
dentists may only register as dentists; dentists may not register as guests.
Name Badge information & fee calculation www.oregondental.org
Mail
(must be received by March 23)
99 Print badge names clearly and include the preferred first name for each person.
99 Make the primary registrant the first entry on the registration form.
99 Enter the appropriate registration code from section  for each person registering.
99 Check whether a Conference Badge (admittance to the Exhibit Hall and all lectures)
or an Exhibits-Only Badge (admittance to Exhibit Hall only) is desired.
99 Enter the appropriate fee according to the date of registration.
99 Check all fee-based courses and events that the registrant will be attending.
99 Total the registration fee plus all fee-based courses and events for each participant.
99 Indicate whether the registrant will be attending the ODC General Session.
99 Enter the 3-digit codes for all NON-fee courses that the registrant will be attending. (All non-fee
codes begin with “2”). Codes will be found on the page opposite the registration form.
Oregon Dental Association
PO Box 3710
Wilsonville, OR 97070
Fax
(must be received by March 23)
99 Add up fees for all registrants and enter the total on the last line of section .
99 Children under 16 are not allowed in lectures, but are welcome in the Exhibit Hall.
housing poll The housing poll helps ODA maintain meeting dates at the Oregon
Convention Center. Make your own hotel reservation, then enter the number of rooms you are reserving
each night next to your hotel. If your hotel is not listed, enter the hotel name on the “other” line. This
information will help us reserve discounted room blocks at popular hotels in the future and is not
intended as a reservation method.
payment Indicate method of payment and be certain that all information is accurate. Credit
card registrations must be signed in order to authorize the transaction. Submit registration by mail, fax,
or online at www.oregondental.org. Registrations will not be accepted by phone or email. If registering
by fax, please do not mail a copy of your registration.
Cancellation Policy: Refund/Cancellation Deadline is March 23.
All refund and cancellation requests must be submitted in writing.
A $50 handling fee will be charged for all refunds.
Refunds will not be accepted, for any reason, after 11:59 pm on March 23,
2012. Registrations may be transferred at any time without penalty.
503.218.2009
credit card orders only
If registering by fax,
DO NOT MAIL a copy of your
registration.
No registrations
will be accepted by phone
or email.
Register online at www.oregondental.org. Early bird pricing through March 9, 2012
Registration ▪ 15
Course Codes
Presenter
Course Title
‡ Courses marked with a double-plus are offered more than once.
See course description for details.
Course Code
Presenter
Course Title
Course Code
Thursday—Full Day Courses
Friday—Morning Courses, cont.
Damm.........................Fire in the Hole....................................................................................... 204
Pine.............................Amazing Race: The Race Against Time................................................ 249
Priest...........................Smile Line Revitalization with Crowns, Veneers and Implants...............221
Reznick........................3-D Radiographic Imaging in Dentistry with Cone Beam Technology.... 251
Rosell..........................Financially Sound in 2012: Live the Life You Have Imagined ‡............. 253
Smith...........................Comprehensive Evaluation ... for Cleft and Craniofacial Patients......... 223
Wakefield....................Restorative Materials: What, Where, Why and How...............................227
Thursday—Morning Courses
Braatz; Kleinstub........Record Keeping from the Board’s Perspective...................................... 202
Braatz; Kleinstub........Ask the Board......................................................................................... 203
Silverman....................Oral Sedation Dentistry ‡....................................................................... 256
Slots............................New Approaches for Antimicrobial Tx of Periodontal Disease ‡........... 258
Soxman.......................Know When to Hold ‘Em and Know When to Fold ‘Em ........................ 259
Vaughan......................CPR for the Health Care Provider ‡........................................................261
de Wette; et al.............Dental Evaluation and Management of the Radiated Cancer Patient... 205
Wood...........................Forensic Case Files: Not Exactly What You See on CSI....................... 263
DiGangi.......................Oral-Systemic Health: Marketplace Realities........................................ 206
Friday—Afternoon Courses
Eshenaur Spolarich....Women and Medications: Health...Pharmacotherapies........................ 208
Beadnell; Ueeck.......... Management of Impacted Teeth: Canines, Second and Third Molars......231
Fleury..........................New Dimensions in Endodontics—Lecture............................................210
Kutsch.........................Caries Risk Assessment: Dental Caries GPS for GPs ‡........................211
DeNoble......................Inside the Dark Side and Drug Addiction: It’s All in Your Brain ‡.......... 234
DePalma.....................Habits of Effective Dental Offices: Do You Have What It Takes?.......... 236
Malmquist...................The Congenitally Missing Tooth: Implant Options for Treatment............213
Fazio...........................Medicine, Dentistry and Drugs .............................................................. 239
McCullough.................. Branding Your Dental Practice: Love Your Brand and Live Your Brand..... 215
Gunn...........................Take Charge Now: QuickBooks Practice Essentials..............................241
Molinari.......................Infections in Immune Compromised Persons.........................................218
Howerton; Kennedy....Medical Emergencies............................................................................. 243
Slots............................New Approaches for Antimicrobial Tx of Periodontal Disease ‡........... 222
Vaughan......................CPR for the Health Care Provider ‡....................................................... 224
Niemczyk..................... Advanced Endodontic Concepts and Tech. for the GP—Workshop......F305
Waldron.......................Dentistry’s Amazing Digital Platform for Restorative Care ‡................. 228
Pine.............................What Are the Odds: It Starts and Ends with You!.................................. 250
Wood...........................Introduction to Forensic Dentistry.......................................................... 230
Reznick.......................Stem Cells: Emerging Medical and Dental Therapies........................... 252
Rosell..........................Financially Sound in 2012: Live the Life You Have Imagined ‡............. 254
Thursday—Afternoon Courses
Beadnell; Ueeck.........Medical Emergency Update....................................................................201
DiGangi.......................Firm Footing on Shifting Ground: Don’t Get Lost in Translation.............207
Eshenaur Spolarich....Managing the Geriatric Patient: Practice Considerations...................... 209
Fleury..........................New Dimensions in Endodontics—Workshop..................................... F301
Kutsch.........................Caries Risk Assessment: Dental Caries GPS for GPs ‡........................212
Malmquist...................Implant Esthetics: Soft Tissue Mgt., Grafting and Temporization..........214
McCullough.................Supercharge Your Productivity: Get a Shot of Energy...........................216
Menage Bernie...........Paradigm Shifts in Periodontal Therapy: Evolving Protocols.................217
Molinari.......................Infection Control: That Thing You Do—Why Do You Do It?...................219
Nový............................My Patient Keeps Getting Cavities, and I Don’t Know What to Do!....... 248
Shelburne.................... Clinical Records Prevent Criminal Records: Do Dentistry, Not Time....... 255
Silverman....................Oral Sedation Dentistry ‡........................................................................257
Soxman.......................Clinical Techniques in Pediatrics............................................................ 260
Vaughan......................CPR for the Health Care Provider ‡....................................................... 262
Saturday—Full Day Courses
Nase............................Suturing Techniques for the General Practitioner—Workshop........... F306
Piñeyro; Wadhwani.....Cement and Its Effects on Implant Restorations....................................277
Raposa.......................Success and Preparation for Special Needs Patients...plus...Autism... 278
Pressnell.....................Exposure Control/Bloodbourne Pathogens........................................... 220
Vaughan...................... CPR for the Health Care Provider ‡........................................................... 225
Sharples......................It’s Not Your Parents’ Dentist: An Overview of New Technology.......... 279
Verbiest.......................Risk Management (as part of ODC registration).................................... 226
Assael; Myall; et al......OSOMS Symposium: Part 1................................................................... 265
Verbiest.......................Risk Management (stand-alone course).............................................. F302
Waldron.......................Dentistry’s Amazing Digital Platform for Restorative Care ‡................. 229
Berkman.....................Advances in Orthodontics: ... Interdisciplinary, and Esthetic................ 268
Wood...........................Forensic Dentistry: Computer Identification Workshop....................... F303
Fazio...........................Periodontitis and Peri-Implantitis: The Good, the Bad and the Ugly..... 270
Saturday—Morning Courses
Beemsterboer; Chiodo...Ethics in the Business of Dentistry...........................................................266
Harper Mallonee.........Healthy Mouth, Healthy Body: Healthy Practice!................................... 272
Friday—Keynote
Nathanson..................Selection and Use of Modern Restorative Materials..............................274
Bell..............................Water the Bamboo: Unleash Your Potential........................................... 290
Staads.........................Get Your ASK in Gear............................................................................. 280
Friday—Full Day Courses
El-Ebrashi...................Implant Therapy for the Edentulous—Workshop................................. F304
Hornbrook...................Hot Topics in Aesthetic and Restorative Dentistry..................................242
Stafford.......................Verbiage: The Power of Storytelling........................................................281
Thompson...................Exploring Sleep Medicine and the Role of the Dental Hygienist........... 283
Vaughan......................CPR for the Health Care Provider ‡....................................................... 285
Nase............................ Clinical Operating Microscopes: Not Just for Endodontists Anymore...... 245
Saturday—Afternoon Courses
Friday—Morning Courses
Allred; Perry................Keeping Ahead of the Fraud Curve........................................................ 264
Chin.............................The Art and Science of Communication................................................ 232
DeNoble......................Inside the Dark Side and Drug Addiction: It’s All in Your Brain ‡.......... 233
DePalma.....................TMD—TMJ: What Is It All About?.......................................................... 235
Dunscombe; et al........Medical Teams International: At Home and Abroad...............................237
Fazio...........................Antibiotics in Dentistry............................................................................ 238
Gunn...........................For Your Eyes (and Ears) Only!: Practice Embezzlement..................... 240
Menage Bernie...........Remineralization Strategies: Fluoride, Calcium, Phosphate Tech........ 244
Niemczyk....................Advanced Endodontic Concepts ... for the GP—Lecture...................... 246
Nový............................Be Very Afraid (If Your Name is Strep Mutans).......................................247
Bell; Dierks; et al.........OSOMS Symposium: Part 2....................................................................267
Berkman.....................Communication in the Office: A Discussion for All Team Members...... 269
Gagneja; Hall ............. “First Tooth” Pregnancy and Beyond......................................................271
Harper Mallonee.........Fattening of America: Where does Dentistry Fit into the Puzzle?......... 273
Nathanson..................Successful Management of the Esthetically Demanding Patient...........275
Peters..........................The Fundamentals ... Advanced Endodontics for GPs.......................... 276
Stafford.......................Parent Perceptions: “But They’re Just Baby Teeth”............................... 282
Thompson...................Dynamic Oral Care Therapies................................................................ 284
Vaughan......................CPR for the Health Care Provider ‡....................................................... 286
Use course codes to indicate which courses each registrant wishes to attend. Make sure the course code you enter on the form corresponds to the day and time that you wish to
take the course. Courses beginning with “2” are included with registration. Courses beginning with “F” require an additional fee.
2012
Preregistration Form
You can also
register online at:
FOR ODA USE ONLY
2012 Oregon Dental Conference
April 12–14 • Oregon Convention Center
 JW  TMP Date______________________ Refund $____________________  Ck  CCProcessed__________________ Confirm __________________ www.oregondental.org
Reason __________________________________________________________
 PRIMARY REGISTRANT
 C heck here if this is a continuation from another registration form. If so, simply
enter the primary registrant’s name in section
and skip to section
.


 REGISTRANT Category & Fees
Conference
badge
Last Name __________________________________ First Name___________________________ Degree ___________
Registration Category
Code
Enter in
Section 4
Before 3/9
Early
On-site
After 3/9
Before 3/9
Early
On-site
ODA member
01
$270
$385
$25
$50
ADA 11th district member (AK, ID, MT, WA)
02
$270
$385
$25
$50
ADA retired or life-retired member
03
$270
$385
N/C
N/C
ADA federal dentist
04
$270
$385
$25
$50
Non-ADA member dentist; Oregon specialty group
partners (OAPD, OSAE, OSOMS, OSP)
05
$270
$385
$25
$50
Retired volunteer dentist in Oregon (with DV license)
06
N/C
N/C
N/C
N/C
ADA member dentist outside 11th district
(not from OR, AK, ID, MT, WA)
07
$300
$440
$25
$50
Non-ADA member or specialty group member dentist
08
$660
$825
$200
$400
Non-dentist faculty
Hygienist
Assistant
Administrative staff
Laboratory personnel
Dental student
Resident/Graduate student
Pre-dental student
Dental hygiene student
Dental assisting student
Non-dental guest (spouses, children over 18)
09
10
11
12
13
14
15
16
17
18
19
$270
$85
$85
$85
$85
N/C
N/C
N/C
N/C
N/C
$85
$385
$175
$175
$175
$175
N/C
N/C
N/C
N/C
N/C
$175
$25
$25
$25
$25
$25
N/C
N/C
N/C
N/C
N/C
$25
$50
$50
$50
$50
$50
N/C
N/C
N/C
N/C
N/C
$50
ADA # ________________________________ Oregon specialty group # _____________________ OAPD, OSAE, OSOMS, OSP only
Dentists must choose from categories 1–8
Mailing address ___________________________________________________________________________________________
City, State Zip ____________________________________________________________________________________________
Email______________________________________________________________________________________________________
Office phone______________________________________ Office fax _____________________________________
Emergency contact Name ___________________________________________________________________________
Dentist Categories
Street Address or PO Box
Emergency contact phone __________________________________ Relationship _________________________________
All registrants must answer the followingYESNO
1. Do you require special assistance at the conference?
1a. If yes, check here for Hearing:
If more than four, please be sure to attach photocopies of this form for additional registrants.
 Specialty (doctors only)
Prosthodontics [I]
Dental public health [J]
Full-time faculty [K]
Retired [L]
Badge Type (choose 1)
Registration Fee
from Section 
nce
Category Code
from Section 
only
Please print or type neatly.
Errors may delay processing
of your registration.
bit-
 Name Badge Information & Fee Calculation
After 3/9
A Conference badge includes all courses (including risk management), entrance to the Exhibit Hall, and admission to non-ticketed special events.
An Exhibits-only badge includes admission to the Exhibit Hall only.
fere
Oral/maxillofacial radiology [E]
Orthodontics [F]
Pediatric dentistry [G]
Periodontics [H]
Co n
General practitioner [A]
Endodontics [B]
Oral/maxillofacial surgery [C]
Oral/maxillofacial pathology [D]
exhi
NON-Dentist Categories
2. Do you want to receive mailings from ODC exhibitors?
3. How many registrants from your office are attending the conference?
Or here for Other:
Exhibits-only
badge
President’s
Reception
DBIC Risk Mgt Only
No admission to
conference or exhibits
1)____________________________________________, _______ ____________________________ ________   $ _________ +  F300: $25 +  F302: $75
Last name
Courses: First name
MI
Degree First name for badge
2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ Workshops:  F301 (Fleury) $100  F303 (Wood) $50 Will Registrant 1 attend the ODC General Session (Course code 290)?  Yes  No  F304 (El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 1 Total Fees: $ ________________
2)____________________________________________, _______ ____________________________ ________   $ _________ +  F300: $25 +  F302: $75
Last name
Courses: First name
MI
Degree First name for badge
2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ Workshops:  F301 (Fleury) $100  F303 (Wood) $50 Will Registrant 2 attend the ODC General Session (Course code 290)?  Yes  No  F304 (El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 2 Total Fees: $ ________________
3)____________________________________________, _______ ____________________________ ________   $ _________ +  F300: $25 +  F302: $75
Last name
Courses: First name
MI
Degree First name for badge
2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ Workshops:  F301 (Fleury) $100  F303 (Wood) $50 Will Registrant 3 attend the ODC General Session (Course code 290)?  Yes  No  F304 (El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 3 Total Fees: $ ________________
4)____________________________________________, _______ ____________________________ ________   $ _________ +  F300: $25 +  F302: $75
Last name
Courses: First name
MI
Degree First name for badge
2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ Workshops:  F301 (Fleury) $100  F303 (Wood) $50 Will Registrant 4 attend the ODC General Session (Course code 290)?  Yes  No  F304 (El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 4 Total Fees: $ ________________
ODA reserves the right to adjust charges due to mathematical or other errors. Registrants who have not paid the appropriate fee will not receive a confirmation until the balance due is paid.
Total fees for registrants 1 through 4 of this sheet = $______________
 Housing Poll
 Check here if you will be
staying in a private home.
Doubletree by Hilton
Portland
Crowne Plaza
Downtown/Conv. Ctr.
Embassy Suites—Downtown
La Quinta Inn Convention Center
Red Lion Convention Center
other__________________
Tue
Enter the number of rooms you are
reserving each night at your hotel. If your
hotel is not listed, use the “other” line.
Wed
Thu
Fri
Sat
Sun
 Payment
 Check  MasterCard  Visa
 Discover  American Express
(Make checks payable to Oregon Dental Association)
Card no. _________________________________________________
Exp. date ___________________ Card billing ZIP Code __________________
Register before March 9, 2012
MAIL
Oregon Dental Association
FAX
503.218.2009
PO Box 3710
(Credit card registrations only)
Wilsonville, OR 97070-3710
WEB www.oregondental.org
Deadlines and policies
Total amt $___________________
Name on card____________________________________________
Print name exactly as it appears on card
Signature___________________________________________________
Signature indicates approval of charges to your account
March 9, 2012: Preregistration discount
deadline. Registrations received after this
date will be processed on site and registration
materials must be picked up at the Badge
Replacement counter at the Convention Center.
Registration confirmations will be sent to
registrants after processing. A packet including
name badge will be mailed prior to ODC.
March 23, 2012: Refund/cancellation
deadline. Refund requests will not be accepted
after this date. All refund/cancellation requests
must be submitted in writing. A $50 handling
fee will be charged for all refunds. Registrations
can be transferred at any time without penalty.
March 23, 2012: Mail/fax registration
closed. Please register online or on site in
Pre-Function A at the Oregon Convention Center.
2012
Preregistration Form
FOR ODA USE ONLY
2012 Oregon Dental Conference
April 12–14 • Oregon Convention Center
SAMPLE
FORM
You can also
register online at:
 JW  TMP Date______________________ Refund $____________________  Ck  CCProcessed__________________ Confirm __________________ www.oregondental.org
Reason __________________________________________________________
 C heck here if this is a continuation from another registration form. If so, simply
enter the primary registrant’s name in section
and skip to section
.


Sample Thomas Q. DMD
Last Name __________________________________
First Name___________________________
Degree ___________
ADA # ________________________________ Oregon
specialty group # _____________________ OAPD, OSAE, OSOMS, OSP only
123456
1250 Main St, Suite 100
Mailing address
___________________________________________________________________________________________
Street Address or PO Box
Someplace OR 97200
City, State Zip ____________________________________________________________________________________________
drsample@gmail.com
Email______________________________________________________________________________________________________
503-123-4567503-765-4321
Jane Sample
Emergency contact Name ___________________________________________________________________________
503-123-4567 Spouse
Emergency contact phone __________________________________
Relationship _________________________________
Office phone______________________________________ Office fax _____________________________________
 REGISTRANT Category & Fees
Conference
badge
Registration Category
All registrants must answer the followingYESNO
1. Do you
require special assistance at the conference?
1a. If yes, check here for Hearing:
Prosthodontics [I]
Dental public health [J]
Full-time faculty [K]
Retired [L]
Before 3/9
Early
On-site
ODA member
01
$270
$385
$25
$50
ADA 11th district member (AK, ID, MT, WA)
02
$270
$385
$25
$50
ADA retired or life-retired member
03
$270
$385
N/C
N/C
ADA federal dentist
04
$270
$385
$25
$50
Non-ADA member dentist; Oregon specialty group
partners (OAPD, OSAE, OSOMS, OSP)
05
$270
$385
$25
$50
Retired volunteer dentist in Oregon (with DV license)
06
N/C
N/C
N/C
N/C
ADA member dentist outside 11th district
(not from OR, AK, ID, MT, WA)
07
$300
$440
$25
$50
Non-ADA member or specialty group member dentist
08
$660
$825
$200
$400
Non-dentist faculty
Hygienist
Assistant
Administrative staff
Laboratory personnel
Dental student
Resident/Graduate student
Pre-dental student
Dental hygiene student
Dental assisting student
Non-dental guest (spouses, children over 18)
09
10
11
12
13
14
15
16
17
18
19
$270
$85
$85
$85
$85
N/C
N/C
N/C
N/C
N/C
$85
$385
$175
$175
$175
$175
N/C
N/C
N/C
N/C
N/C
$175
$25
$25
$25
$25
$25
N/C
N/C
N/C
N/C
N/C
$25
$50
$50
$50
$50
$50
N/C
N/C
N/C
N/C
N/C
$50
After 3/9
A Conference badge includes all courses (including risk management), entrance to the Exhibit Hall, and admission to non-ticketed special events.
An Exhibits-only badge includes admission to the Exhibit Hall only.
Category Code
from Section 
Badge Type (choose 1)
Registration Fee
from Section 
nce
Please print or type neatly.
Errors may delay processing
of your registration.
x
President’s
Reception
only
 Name Badge Information & Fee Calculation
After 3/9
bit-
Oral/maxillofacial radiology [E]
Orthodontics [F]
Pediatric dentistry [G]
Periodontics [H]
On-site
fere
Endodontics [B]
Oral/maxillofacial surgery [C]
Oral/maxillofacial pathology [D]
Early
exhi
 Specialty (doctors only)
x General practitioner [A]
2
Before 3/9
Co n
If more than four, please be sure to attach photocopies of this form for additional registrants.
x
Or here for Other:
NON-Dentist Categories
2. Do you want to receive mailings from ODC exhibitors?
3. How many registrants from your office are attending the conference?
x
x
Code
Exhibits-only
badge
Enter in
Section 4
Dentists must choose from categories 1–8
Dentist Categories
 PRIMARY REGISTRANT
DBIC Risk Mgt Only
No admission to
conference or exhibits
x
Sample Thomas Q. DMD Tom
01   $ _________ $270 + F300: $25 +  F302: $75
1)____________________________________________, _______ ____________________________ ________ Last name
Courses: First name
MI
Degree First name for badge
x
45 63 2__03 __ 2__
__ 2__
__ 2__66
__ 2__ __ 2__ __ 2__ __ 2__ __ Will Registrant 1 attend the ODC General Session (Course code 290)?  Yes  No  F304
(El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 1 Total Fees: $ ________________
$495
x
Johnson Mary A. RDH Mary
10 x  $ _________ 85 + x F300: $25 +  F302: $75
2)____________________________________________, _______ ____________________________ ________ Last name
First name
MI
Degree First name for badge
03 45 63 Courses: 2__
__ 2__
__ 2__
__ 2__66
__ 2__ __ 2__ __ 2__ __ 2__ __ Will Registrant 2 attend the ODC General Session (Course code 290)? x
 Yes  No $160
Workshops:  F301 (Fleury) $100  F303 (Wood) $50 x
 F304
(El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 2 Total Fees: $ ________________
x
Workshops:  F301 (Fleury) $100  F303 (Wood) $50 3)____________________________________________, _______ ____________________________ ________   $ _________ +  F300: $25 +  F302: $75
Last name
Courses: First name
MI
Degree First name for badge
2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ Workshops:  F301 (Fleury) $100  F303 (Wood) $50 Will Registrant 3 attend the ODC General Session (Course code 290)?  Yes  No  F304 (El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 3 Total Fees: $ ________________
4)____________________________________________, _______ ____________________________ ________   $ _________ +  F300: $25 +  F302: $75
Last name
Courses: First name
MI
Degree First name for badge
2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ 2__ __ Workshops:  F301 (Fleury) $100  F303 (Wood) $50 Will Registrant 4 attend the ODC General Session (Course code 290)?  Yes  No  F304 (El-Ebrashi) Dentist $100; Staff $50  F305 (Niemczyk) $100  F306 (Nase) $100 Registrant 4 Total Fees: $ ________________
ODA reserves the right to adjust charges due to mathematical or other errors. Registrants who have not paid the appropriate fee will not receive a confirmation until the balance due is paid.
Total fees for registrants 1 through 4 of this sheet = $______________
 Housing Poll
 Check here if you will be
staying in a private home.
Doubletree by Hilton
Portland
Crowne Plaza
Downtown/Conv. Ctr.
Embassy Suites—Downtown
La Quinta Inn Convention Center
Red Lion Convention Center
other__________________
Tue
Enter the number of rooms you are
reserving each night at your hotel. If your
hotel is not listed, use the “other” line.
Wed
Thu
Fri
Sat
2 21
Sun
 Payment
x
 Check  MasterCard  Visa
 Discover  American Express
(Make checks payable to Oregon Dental Association)
1234 - 5678 - 4567 - 6543
05/13
ZIP Code __________________
97200
Exp. date ___________________ Card billing
Card no. _________________________________________________
$655
Total amt $___________________
Thomas Q. Sample
Name on card____________________________________________
Print name exactly as it appears on card
Thomas Q. Sample
Signature___________________________________________________
Signature indicates approval of charges to your account
$655
Register before March 9, 2012
MAIL
Oregon Dental Association
FAX
503.218.2009
PO Box 3710
(Credit card registrations only)
Wilsonville, OR 97070-3710
WEB www.oregondental.org
Deadlines and policies
March 9, 2012: Preregistration discount
deadline. Registrations received after this
date will be processed on site and registration
materials must be picked up at the Badge
Replacement counter at the Convention Center.
Registration confirmations will be sent to
registrants after processing. A packet including
name badge will be mailed prior to ODC.
March 23, 2012: Refund/cancellation
deadline. Refund requests will not be accepted
after this date. All refund/cancellation requests
must be submitted in writing. A $50 handling
fee will be charged for all refunds. Registrations
can be transferred at any time without penalty.
March 23, 2012: Mail/fax registration
closed. Please register online or on site in
Pre-Function A at the Oregon Convention Center.