New Member Registration


Step 1
We need a few bits of information to get you setup. Make sure that you enter the required information before continuing onward. All required fields have a orange "R" next to them.

Step 2
When you are done, click the blue "Create Account" button all the way at the bottom of the page. Pleaase note that when you are done, you will be directly loged in to the homepage.
 

Step 4
Need some help?.
Personal Information
Do Not Publish Info Online:
Do Not Contact By Phone:
Do Not Contact By Fax:
Do Not Contact by E-mail:
Do Not Contact By Mail:

Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Designation:
 
Parental Consent
As per GDPR compliance requirements, association staff may reach out to the guardian listed in the Name and Contact Information fields above. Please provide a contact number and/or email address where your guardian may be reached.
 
I am a minor
 
Address Information
Please select your country first and the “State” input field will be populated with available states, provinces or territories of your country.
 
Work Address:
City:
State:
Postal Code:
Country:
Is Primary Address:
Show in Directory:
 
Home Address:
City:
State:
Postal Code:
Country:
Is Primary Address:
Show in Directory:
 
Phone Information
Work Phone:
   
Ext: 
   
Primary: 
Home Phone:
   
Ext: 
   
Primary: 
 
E-Mail Address Information
A primary e-mail address is required for using this web site. It will be used as the login ID to be able to log in to the site.
 
Work E-Mail:
    Primary: 
Home E-Mail:
    Primary: 
 
Password needs to be at least 6 characters in length.
 
Password:
Confirm Password:
 
 Please provide the following additional information
 Dental School Graduation Year: 
 Membership Type: 
 
 
Warning! You still have not identified which method you would prefer to be contacted by. Please return to the top of the page and identify a method you would like to be contacted by.