To Promote Excellence in Operative Dentistry
First Name
Last Name
Mobile phone:
Phone
Fax
Email
Are you a dental student or a dental resident? == choose one == YES NO
If you are a dental student (D1-4) or a dental resident (R1-3), what year of your program are you currently in? D1 D2 D3 D4 R1 R2 R3 Use ctrl-click or shift-click to select multiple items.
Degree(s) DMD DDS BDS BDent MSc MSD MMSc MDent MDS DDSc DScD GPR Zahnarzt PhD Certificate Diploma Other:
Honorific == choose one == Dr. Mr. Ms. Miss Mrs. Prof
Professional Status: == choose one == Dental Student Resident Private Practice Academics Research
Street Address
City (or APO/FPO/DPO)
Province/State == choose one == -- Province -- AB BC MB NB NL NT NS ON PE QC SK YT -- State -- AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY Outside Canada/US AE AA AP
Postal/Zip Code
What is the topic or title of your presentation?
Synopsis (60 Words Max, to Be Printed in Meeting Program)
Learning Objectives (3 in point form)
Provide a link to video clip of your presentation here:
If Dental Student/Resident, your sponsor:
School or Institution (Mandatory for Students/Residents)
Abstract (500 words or less)
City
Province/State == select == ==Canada== AB BC MB NB NL NS NT NU ON PE QC SK YT ==USA== AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MR MS MT NC ND NE NH NJ NM NN NV NY OH OK OR PA PL PO PR RI SC SD TN TT TX UT VA VI VT WA WI WV WY ==other/international==
Principal Interests == select == Orthodontics Implant placement Implant restoration In-site CAD/CAM restorations Invisalign Endodontics Periodontal therapy Occlusal therapy/TMD treatment Esthetics dentistry Oral surgery Complex oral rehabilitation Gold foil restorations Conservative cast gold restorations Non-surgical caries management
