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Password:

MEMBERS | Registration Form


Please use the secure online registration form below. Fill out all fields which apply to your practice.

Or download this printable member registration form and mail it to us.

For further information:
Contact Marcy Sharp, Director of Operations 631-265-4442


2008-2009 Member Registration

Doctor's Name: DDS DMD
Office Name:
Office Telephone: Home Telephone:
Address:
E-mail: Website:
Fax:
AGD#: ADA#:
Cell #: Pager #:

Staff Members

FRONT OFFICE / ADMINISTRATIVE STAFF

Name Title
1.
2.
3.
4.



CLINICAL STAFF

Name Title
1.
2.
3.
4.

 

Please make checks payable to: Long Island Dental Forum in the amount of $1595
for the 2008-2009 year $1495 if paid prior to August 11, 2008 NO EXCEPTIONS

Credit card payments will be accepted. Contact our office to pay by credit card.
For further information, contact Marcy Sharp, Director of Operations 631-265-4442 or by email.