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 ____________________________________________________________________________________________ [email protected] 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.
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