Already an ADA dentist member and just moved to Arizona?
Fill out this transfer application for the Arizona Dental Association:
(
*
= Required Fields)
Information:
*
Full Name
(First Middle Last)
Phonetic Pronunciation
(To help us pronounce your name when we give referrals)
ADA Member Number
*
Arizona Dental License
Date of Birth
(mm/dd/yyyy)
Gender
M
F
Spouse Name
Email
(We do not share/publish member email addresses)
Where are you transfering from
ADA Direct Member
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Preferred Mailing Address:
*
This Address Is
Home
Office #1
Office #2
*
Address
*
City
*
State
*
Zip
*
Phone
Fax
Website
Secondary Address:
This Address Is
Home
Office #1
Office #2
Address
City
State
Zip
Phone
Fax
Website
Alternate Address:
This Address Is
Home
Office #1
Office #2
Address
City
State
Zip
Phone
Fax
Website
Social Media for your Office:
Facebook:
Twitter:
LinkedIn:
Education:
Please indicate ADA-reconignized specialty you are limited to
General Practitioner
Endodontics
Pediatric
Public Health
Periodontics
Prosthodontics
Oral Pathology
Oral Surgery
Oral Radiology
Orthodontics
*
Dental School
*
Graduation Date
Degree Earned
Internship/Military
From
To
Post Graduate Training
From
To
Other Training
Membership Agreement:
I HEREBY APPLY for membership in the American Dental Association, Arizona Dental Association and my local dental society and resolve to abide by the
Constitution and Bylaws
,
Principles of Ethics and Code of Professional Conduct
and the
Peer Review Program
of each organization, if elected for membership.
I CERTIFY THAT all statements made by me in this application are complete, true and honest. I understand and agree that if any statement is found to be false or omitted, this application may be rejected solely for that reason. I also understand and agree that in the event such false statement(s) or omission(s) does not become known to the Dental Society until after I have been elected, I understand my membership may be terminated immediately on the basis of incomplete or false information. For the purposes of this paragraph, I understand that a material misstatement or omission shall mean, one which is "significant in relation to the questions asked to which the false statement or to which the omission was made."
I FURTHER AGREE that I will recognize the authorized officers of my local dental society and said Association as the proper and sole authorities to interpret all areas of professional conduct and interpretations.
UPON BECOMING A MEMBER of the local dental society, Arizona Dental Association and the American Dental Association, I hereby waive the right to hold this society, the Association or any member thereof, responsible for any damage in case of disciplinary action involving me, after a hearing in accordance with the Bylaws of this society, the Arizona Dental Association and the American Dental Association.
*
I have read and understand the above membership agreement.
I was referred/recruited to membership by Dr.
Referral Information:
The Arizona Dental Association provides approximately 500 patient referrals each week. So that we can provide the most up-to-date information about your practice, please check each service your dental office provides.
Bleaching/Whitening
Cancer Patients
(Radiation & Chemo Therapy)
Dental Phobias
Dentures
Emergencies
Evening Hours
Financing, Tx
Friday Hours
General Anesthesia
Hospital Privileges
Implants
Children 0-5 yrs old
IV Sedations/
Anesthesia
Lasers
Latex Allergies
Saturday Hours
Senior Discounts
Sign Language
Nitrous Oxide
Nursing Home Calls
Oral Conscious
Sedation
Special Needs
TMJ/TMD
Wheelchair Bound
Patients
Foreign Languages:
Volunteering:
Please indicate the coucils/committes on which you have interest in serving.
Ethics/Peer Review
Membership
Volunteer Opportunities
Communications
Continuing Education
Donated Dental Services
Dental Health
New Dentist Activities
Foundation Activites
Legislation
Speaker's Bureau
Fundraising
Practice/Occupation:
Tell us about your occupation:
Tell us about your practice setting:
Owner Private Practice
Non-Owner
Associate
Owner-Group Practice
Non-Owner Group Practice
Associate-Group Practice
Independant Contractor
Full-time Practice 30+ hrs
Part-time Practice
Dental School Faculty
Armed Forces
Other Federal Service
In a Graduate Program
Seeking Employment
Non Longer in Practice
What challenges in particular are you encountering in your practice/career?
How can we help?
What is the most valuable benefit the Association provides or should provide?
Why did you decided to join AzDA?
Note: As a member, you can login to the "Members Area" of this website to update this information if it changes.