American Dental Assistants Association 2009 Catalog

AMERICAN DENTAL
ASSISTANTS
ASSOCIATION
2009ADAA
EDUCATION
DELIVERING EXCELLENCE IN PROFESSIONAL DEVELOPMENT FOR DENTAL ASSISTANTS
WHEN JUST GOOD

ENOUGH ISNT ENOUGH
GO FOR THE BEST
WEVE GOT
EVERYTHING
YOU NEED FOR
LIFETIME LEARNING
IN DENTAL ASSISTING
NEW FOR
09
The Art and Science of

Tooth Whitening
The Business of Dentistry:

Admininistrative Skills
The Business of Dentistry: Patient

Appointments and Scheduling
Inflammation: The Relationship

Between Oral Health and
Systemic Disease

Financial Management for the
Dental Office
Patient Care Coordinator: Are You

Ready for a Challenge?
Xerostomia: Recognition and

Management
Addressing Language and

Cultural Barriers of
the Spanish Speaking Patient
Hand Hygiene for the Dental

Professional
CONTINUING EDUCATION
WORKBOOK COURSES
ADAA FOUNDATION
The American Dental Assistants Association

Foundation was established to fund education
and research for all dental assistants. The
foundation is a nonprofit organization funded by
dental corporations, state and local ADAA
components, individual ADAA members and
other interested parties. The American Dental
Assistants Association wishes to thank all
foundation contributors for their support of the
dental assisting profession.
INTRAORAL FUNCTIONS
General Chairside Assisting:
A Review for a National Chairside Exam
This course reviews the major aspects of general chairside assisting. It addresses clinical data collection and recording, preventing/managing emergencies, chairside and laboratory
materials and procedures, dental instruments, patient education
and oral health management, oral anatomy, oral pathology, pharmacology, anesthesia, dental specialties, and office operations.
Developed as a preparation aid for the Dental Assisting National
Boards General Chairside Exam.
Course Number: 0613
CE Credits: 24 Hours
ADAA Member: $88 :: Nonmember: $115
Alginate Impression and Diagnostic

Study ModelTechniques
Learn stepbystep procedures for taking
alginate impressions. Discover alternatives for obtaining bite registrations. Ascertain various ways of creating study models.This comprehensive
course combines theory with practical information to teach correct chairside and laboratory procedures and how to manipulate
the dental materials involved. Highlights infection control including disinfection protocol, patient preparation, mixing techniques,
alginate tray selection and preparation, use of adhesives, seating
and removal of impression trays, inspection of impressions, bite
registration techniques, gypsum, pouring casts, separating and
trimming casts, and finishing and storage of models. Sponsored
in part from an educational grant from DUX Dental.
UPDATED
09
Course Number: 0806
CE Credits: 3 Hours
Local Anesthesia in Todays Dental Practice

The success of contemporary dental practice largely hinges on
the use of local anesthesia for patient comfort and safety. Dental
assistants should have a basic understanding of local anesthesia, proper methods for handling syringes, possible complications, and how to manage emergencies.
Course Number: 0517 CE Credits: 2 Hours
Air Abrasion in Dentistry

This course familiarizes dental assistants with the history and applications of air abrasion and addresses new equipment and materials that have revived interest in the technology. Both low and
high pressure air abrasion procedures are explained, as are their
applications and common problems.
Course Number: 9801 CE Credits: 1 Hour
The Use of Pit and Fissure Sealants

in Preventive Dentistry
It is the responsibility of dental professionals to assess each patient for possible sealant placement. Long term success of
sealants relies heavily on placement technique, patient education,
and recare appointments.Types of materials available and placement
procedures will also be discussed. Sponsored in part from an educational grant from 3M ESPE.
Wired for Learning Orthodontic Basics

Orthodontics specializes in the diagnosis,
prevention and treatment of dental and facial irregularities, but from a patients view,
it simply creates great smiles! This course introduces the general
dental assistant to basics of orthodontics, with the goal of peaking
interest in this specialty of dentistry, and providing education to
springboard an individual considering a career in this specialty.
UPDATED
09

Setting it Straight Advanced Orthodontics

Extending beyond the content covered in the basic orthodontics
course, this course includes information on the six keys to occlusion, orthodontic bonding materials and techniques, instrumentation, archwire alloys, early treatment considerations,
treatment risks and limitations, and the latest technologies, with
the goal of familiarizing dental assistants with the more advanced aspects of orthodontics.
WORKBOOK COURSES CONTINUING EDUCATION

PowerToothbrushes: EverythingYou Need to
Know to Make Informed Recommendations for
Your Patients
Are you overwhelmed with questions from your patients about
power toothbrushes? Feel like you cant keep abreast of the newest
products on the market and their effectiveness? This course describes the newest products, safety, selection parameters, and patient instruction. Learn how to locate and use current research to
make informed recommendations for your patients. Sponsored in
part from an educational grant from OralB.
Maxillofacial Surgery Basics for the Dental

Assistant Part I
This course reviews the role of the dental
assistant in preparing a client for oral surUPDATED
gery procedures, whether performed in
the general dental practice or specialty clinic. Areas reviewed include medical assessment, regional surgical anatomy, anesthesia,
sedation, and management of hemorrhaging.
09

Maxillofacial Surgery Basics

for the Dental Assistant Part II
Independent of Part I in this series, this course reviews the basic
principles of oral surgery, including reasons for extractions, basic
and surgical techniques, flap designs, management of impacted
teeth, and instrumentation. It is designed to give the dental assistant insight into how oral surgical procedures are performed.
Fabrication of Provisional Crowns and Bridges

This course gives dental assistants the
knowhow to fabricate temporary
UPDATED
crowns and bridges. Includes information on materials, detailed instruction on fabrication techniques,
finishing, polishing and cementing procedures. Sponsored in part
from an educational grant from 3M ESPE.
09

Oral Health Maintenance of Dental Implants

With the demand for dental implants rising, techniques as well as the benefits
to patients have improved. Oral hygiene maintenance by the patient directly affects the prognosis
and success of an implant. This course discusses the required
longterm professional and home care maintenance to ensure a
healthy periimplant program. Stepbystep procedures for
patients are included.
UPDATED
09
Course Number: 0814

ADAA Member: $25 ::
CE Credits: 2 Hours
Nonmember: $37
Dental Implants: A Second Chance at

Dental Health
With the increasing popularity of dental implants, the role of the
dental assistant has become integral to successful treatment.
Learn how to help patients and dentists enjoy the benefits of dental implant therapy. The course covers the history of dental implants, applications for their use in everyday practice, benefits
and risks, clinical protocols, and sterilization and handling. A
comprehensive overview is designed exclusively for surgical and
restorative assistants.
The Art and Science ofTooth Whitening

One of the fastest growing areas of esthetic
dentistry today is the management of
NEW
discolored and hypoplastic dentition. Tooth
whitening (sometimes referred to as bleaching) is a popular
available option. This course will cover whitening success
factors, various systems, mechanism of action, and side effects.
Sponsored in part by an educational grant from Ultradent
Products.
09
Available only online at www.dentalassistant.org

TREATMENT OF
DISEASES/CONDITIONS
Home Irrigation: An EvidenceBasedTherapy
Gingival Health Periodontal Assessment
This course focuses on the effectiveness of home irrigation as an

important selfcare therapy.The module covers the benefits of oral
irrigation for gingivitis, periodontal maintenance, and special
needs patients, including those with implants, orthodontics, and
diabetes. Also covered are the types of antimicrobial irrigants, selection of tips, and proper use of an oral irrigation device.
An introduction to finding, locating, and assessing periodontal

diseases. Included is the importance of the initial examination,
the recording of indepth information in the patient record, and
types of clinical evidence that can be found on radiographs. Also
covered are the pitfalls involved with inaccurate sulcus depth
readings, mobility and furcation classifications.


WORKBOOK COURSES
Diabetes and Periodontal Health

Due to the growing number of individuals with diabetes, most
dental practices are likely to treat patients with this disease. This
course includes helpful information for dental professionals to
meet the challenges of treating this patient population.
Prevention and Management of Oral

Complications of CancerTreatment:The Role of
the Oral Health CareTeam
The useful information in this course
was drawn from many impressive
sources including the National Institute
of Dental and Craniofacial Research through its National Oral
Health Information Clearinghouse, National Cancer Institute and
others. Our course is presented especially for the dental assistant in a clear, precise edited format. Clinical professionals and
everyone in the field will welcome the insight into this vital
subject.
UPDATED
09

Oral Cancer Genetics: From Diagnosis

toTreatment
Understanding oral cancer genetics can help dental professionals treat patients immediately after diagnosis, during cancer therapy, and after the cancer has been eliminated. Learn to recognize
signs and symptoms, the effects of various cancer treatments on
the oral cavity, and how to ease patient discomfort.
Osteoradionecrosis: Oral Health and

DentalTreatment
Osteoradionecrosis is a potentially debilitating complication of radiation therapy used to treat carcinomas in and around the oral
cavity. Diagnosis, pathogenesis, prevention, and treatment are reviewed, including oral health recommendations, and hyperbaric
oxygen is described as a preventive and treatment modality.
Understanding Nicotine Addiction and InterventionTechniques for the Dental Professional

In recent years, the stage has been set for all dental professionals to become actively involved as facilitators and leaders in tobacco education and control efforts. The course is designed to
teach professionals specific skills they may utilize to help tobacco
users become free of their addiction.
Understanding Meth Mouth and Oral

Interventions
Methamphetamines (MA) directly affect a person's health,
lifestyle, ability to function and mental status. Unlike many other
street drugs, the use of meth is on the rise. Dental professionals
must have knowledge of the symptoms of use, possible side effects, drug interactions with medications and dental treatment
considerations.This will aid in delivering appropriate dental treatment, intervention, patient education and prevention.
Understanding the Dangers and Health

Consequences of SpitTobacco Use
While cigarette use is declining among adults and leveling off in
teens, spit tobacco consumption is on the rise. Even as the popularity of this known carcinogen reaches record levels among
young people, spit tobacco use continues to receive relatively little attention as a public health issue.The dental team is in an ideal
position to use the teachable moments that occur during a dental visit to counsel patients on the dangers of tobacco use and support them in cessation efforts.
Blood Pressure Guidelines and Screening

Techniques
This course teaches the dental health
professional to be aware of the causes
of hypertension. It describes the appropriate method of taking blood pressure and how to determine
recommendations for followup and lifestyle medications for patient treatment.
UPDATED
09

Complementary and Alternative Medicine

Techniques Available for Dentistry
Complementary and alternative medicine used in dentistry is inclusive of various treatment modalities. Dental patients continue
to request these therapies to prevent invasive procedures, relieve
anxiety, and save on cost. Many different methods of alternative
treatment are covered.
An Introduction to the Herpes Viruses

The herpes viruses continue to affect patients worldwide.The use
of immunosuppressant medications, the AIDS epidemic and
crowded living conditions will continue to present a challenge to
our healthcare system. Learn the symptoms, epidemiology, transmission, and treatment of various types of herpes viruses.

The Dental Assistants Management of Medical
Emergencies
Improve your ability to plan for, manage
and handle office medical emergencies
as part of the dental team. Includes discussion of the importance of a thorough health history in dealing
with medical emergencies, background information on emergencies, vitals and what should be included in office emergency
equipment. Also provides scenarios of medical emergency situations and how to handle them.
UPDATED
09

Eating Disorders Understanding the Dental

Ramifications
An eating disorder is a term used to describe health and psychological disorders characterized by a disturbance in ones attitude and
behaviors relating to eating, body weight, body image and thoughts
about ones self.There are many different types of eating disorders
encountered within the dental field.This course will survey some of
the more common disorders encountered in dentistry today.
Course Number: 0611
CE Credits: 3 Hours
Geriatric Dentistry: Reviewing for the Present,

Preparing for the Future
The physical and dental characteristics of
aging are examined in this course. It reUPDATED
views medical conditions that affect preventive and restorative treatment and offers a variety of resources
for patients with xerostomia and physical disabilities. Understanding
these concepts can better prepare dental team members for interaction with this fast growing group of individuals.
09

SportsRelated Dental Injuries and

Sports Dentistry
Participants learn about soft tissue injuries, jaw fractures,TMJ injuries and other problems related to sports injuries. Emergency
treatment is discussed. Statistics relating to sports/dental injuries
are presented as well as differentiating mouth guard types available and patterns of wearing by males and females, cultural differences and effect of peer pressure.
Current Concepts in Preventive Dentistry

Dentistry in the United States today includes preventive practices (prophyUPDATED
laxis, fluoride treatments, full-mouth
and bite-wing radiographs, and sealants) and early detection of dental caries and periodontal disease.This course outlines aspects of pre-
09
vention that dental professionals should address during patient examinations. Sponsored in part by an educational grant from P & G
Crest OralB.
Inflammation:The Relationship Between Oral

Health and Systemic Disease
The purpose of this course is to review how the
inflammation process functions in the human
NEW
body. The role of inflammation in oral and
systemic health will be discussed. Translating this information
into practical application for dental healthcare professionals will
be addressed so that both inquiring patients and astute clinicians
can capitalize on the opportunities for improving total health.
Sponsored in part by an educational grant from Colgate.
09

Importance of Oral Hygiene During Orthodontic

Treatment
A rigorous oral hygiene regimen during orthodontic therapy is
important to help prevent softtissue problems. Consideration
should be given to including the prophylactic use of antimicrobial
rinses. The use of oral medications to relieve pain and promote
healing or oral irritations may also be warranted in individual patients. It is important that the clinician obtain patient commitment
and adherence to an appropriate oral hygiene regimen.
Xerostomia: Recognition and Management

It is important to perform a complete evaluation
of the patient with dry mouth, determining, if
possible, the cause of the xerostomia so that
appropriate management can be instituted in a timely manner.
This course will review methods of evaluation for xerostomia and
practical measures for management of the patient with dry
mouth. Sponsored in part by an educational grant from Colgate.
NEW
09

RADIOLOGY
Introduction to Basic Concepts
in Dental Radiography
Prep for a National Radiology Exam! Included in this factfilled
course are all the basics needed to expose high-quality radiographs. It is the best help a dental assistant can get in prepping
for a radiology exam. Learn how to:
Promote radiation safety
Mount and label exposed radiographs
WORKBOOK COURSES
Identify and correct errors related to dental x-ray procedures

Apply infection control techniques to dental x-ray procedures
Process radiographic film
Expose and evaluate dental radiographs; and
Implement quality assurance procedures in dental
radiography facilities.

Digital Radiography in Dentistry: Moving from

FilmBased to Digital Imaging
The latest advancement in dental radiography is the use of digital technology in recording dental structures. Information included in this course provides the clinician with a basic
understanding of digital imaging technology, necessary equipment, digital imaging receptors, imaging technique, acquisition,
enhancement, transfer, and storage. Comparisons with
filmbased imaging as well as the diagnostic utility of digital images are discussed.
Radiation Biology, Safety and Protection for

Todays Dental Assistant
This summary demonstrates how the study of radiation biology
began and how radiation safety and protection measures evolved
from early research efforts to formally established organizations
that examine leading scientific thought and provide guidance and
recommendations on radiation protection and measurement.The
subsequent information will provide an overview of radiation biology and the safety and protection measures that the dental assistant can implement to reduce radiation exposure to dental
patients and minimize occupational exposure.
Intraoral RadiographicTechniques
When examined under proper conditions, diagnosticquality intraoral radiographs reveal evidence of disease that cannot be
found in any other way.The course presents basic principles and
concepts of intraoral procedures. Includes discussion of proper
techniques for bitewing radiography as well as the use of paralleling and bisecting angle techniques.
Diseases of theTeeth and Jaws

Learn to recognize the radiographic appearance of dental caries,
periodontal disease, periapical pathology, and healing of extraction wounds.This course also focuses on the appearance of conditions such as tooth and bone fractures, developmental
anomalies and regressive changes of the teeth, and developmental abnormalities of the skull and jaws.
Dental Radiographic Pitfalls and Errors

Operator error is the cause of the majority of dental radiograph
retakes. Operator error can occur while exposing or processing
films and is due to incorrect or improper techniques. A routine
using correct technique for exposing and processing films is
critical to maximizing the information garnered from dental
radiographs while minimizing patient exposure to radiation.
PRACTICE MANAGEMENT
The Language of Dentistry
Dentistry has a vast and precise language that may be difficult to
understand by people new to the healthcare professions. As a
healthcare worker, it is important to speak the language with office staff and other healthcare entities and to also translate technical terms to the patient. This course includes root words,
prefixes, suffixes, abbreviations, and acronyms commonly used
in dentistry.
The Dental Assistants Role in Identifying and

Preventing Family Violence
Abuse and neglect are growing at everincreasing rates in the
United States. It not only is within the purview of dental practice
to identify and report suspected cases, it also is required under
state law. An appropriate child abuse and neglect protocol in the
dental office may be the best defense for children in these unfortunate situations. Be aware of warning signs, know what to
consider when an injury is identified, and know how to report suspected cases.
Maintaining Proper Dental Records

Maintaining complete and accurate records is a sign of quality
care and an integral part of the dental teams responsibilities to
its patients. Practical information and the background needed to
maintain a patient chart are included. Guidelines for minimizing
exposure to legal risk, HIPAA (including the Privacy and Security
Rules), procedures for correcting an entry, and other areas of vital
patient record concern are detailed.

The Business of Dentistry: Admininistrative Skills
This comprehensive course covers an overview
of basic concepts and administrative proceNEW
dures of dental practice management. Areas
covered include patient data, general office management, HIPAA
regulations, clinical considerations, patient communications, appointment control, accounts payable and receivable, third party
carriers, records management, inventory control, infection control AND MUCH MORE.
09
Addressing Language and Cultural Barriers of

the Spanish Speaking Patient
The Hispanic population has exhibited tremendous growth in the United States and is impacting many unprepared dental practices.
Intended to help dental professionals improve their communication with Spanish-speaking patients, emphasis on basic common
dental terminology and Hispanic culture and traditions is included.
This course is approval by the Hispanic Dental Association
NEW
09

A CDRom including common Spanish words and phrases

needed in dentistry is also included.
Basic Concepts of Dental Practice Management
Course Number: 0709 CE Credits: 2 Hours with CD

This course for dental administrative assistants offers an overview

of the skills needed to successfully implement basic business concepts, including office design and arrangement, appointment management, telecommunications, financial transactions, insurance
management, recall, inventory, and the basic components of the
federal HIPAA regulation.
Advanced Dental Practice Management Concepts

For the dental assistant whose primary responsibility is managing
the dental office, this course summarizes common responsibilities
of a dental office manager including decisionmaking, hiring, orienting and supervising employees, and assisting in business office
functions while integrating current technology into the practice.

Financial Management for the Dental Office
The administrative assistant plays a key role in
the smooth operation of any dental practice.
How a dental practice receives monies for services rendered and makes payment to outside entities is the focus
of this course. After completing this course the administrative
assistant will be able to apply standard financial procedures to
any dental practice.
NEW
09

Introduction to Computerized Dental Systems

This course provides an overview of the functions available to enhance todays dental practice with computers. Emphasis is placed
on choosing a dental computer system that meets office needs.
The course addresses computerization of patient accounts, appointment scheduling, insurance processing, and billing and
management reports. It also outlines data entry and retrieval,
HIPAA and system management.

Patient Appointments and Scheduling
Scheduling appointments is important to assure smooth patient flow, maximize productivity and make effective use of practice time. To
perform this function the dental business assistant must understand dental procedures as they relate to time duration, office
protocol, scheduling preference, and infection control procedures
needed between appointments. The course will also review basic
dental office communication to ensure patient needs are being
met through the services provided.
NEW
09
Course Number: 0816

ADAA Member: $30 ::
CE Credits: 3 Hours
Nonmember: $43
Designing a Comprehensive Health History

A guideline for creating or updating medical/dental history forms
for any dental practice, this course emphasizes risk management
and quality patient care. Learn the basic components of a patient
medical history, including the legal, ethical, and treatmentrelated
items that must be represented as well as requirements for confidentiality and updates of information. Suggestions are included
for screening patients for systemic conditions, following CDC
guidelines, and treatment protocols.
Patient Care Coordinator: AreYou Ready for a

Challenge?
The purpose of this course is to introduce the
concept of a patient care coordinator (PCC) to
NEW
the dental team. The PPC can be a vital and
integral team member, enhancing the introduction of new
patients into the practice, and facilitating the timely and
coordinated progression of treatment for the patient. This course
will outline the patient responsibilities, requirements, and
interactions with the other team members of the patient care
coordinator.
09

WORKBOOK COURSES
PHARMACOLOGY
Eastern Medicine Meets Dentistry:The Use of
Herbal Supplements in Dentistry
With the widespread use of herbal supplements in the busy lives
of our patients today it is important for the dental team to become familiar with the more commonly used supplements and
possible contraindications for dental treatment. This course will
cover some of the more popular herbals, alternative uses in dental treatment, and potential drug interactions with commonly
used drugs in dentistry.
The Importance of Pharmacology in Dental Care

This comprehensive learning and reference tool for dental assistants describes
prescription and overthecounter medications, their uses in treating patients, and common side effects
and contraindications. It reviews various types of drugs by classification and action and addresses prescription writing, federal control, and the use of drug reference guides.
UPDATED
09

INFECTION CONTROL &

OCCUPATIONAL SAFETY
The Flu.AndYou
Infection Control in the Dental Office:

A Review for a National Infection Control Exam
All aspects of infection control in the dental practice setting are covered. Included are sections on basic microbiology and disease
transmission, immunizations, medical histories and standard precautions. Infection control guidelines, regulations, and standards
are highlighted. Sponsored in part by an educational grant from the
Organization for Safety and Asepsis Procedures (OSAP).
Guidelines for Infection Control

in Dental Health Care Settings
Understanding current infection control regulations and recommendations for dental settings is critical to ensuring the health and
safety of patients and dental team members. The CDCs Guidelines for Infection Control in Dental Health-Care Settings, 2003
sets a standard of care for dental infection control. Dental offices
also must comply with OSHA mandates as well as any state and/or
local regulations.This course reviews significant infection control
publications and supports optimal dental infection control and
safety.
Hepatitis: What Every Health Care Worker

Needs to Know
An overview of the hepatitis A, B, C, D, and E viruses (with special emphasis on the bloodborne viruses B, C, and D), this course
explains modes of transmission, epidemiology, and preventive
measures against these potentially life-threatening infections.
Risks in the dental setting are addressed, and important precautions are described, including vaccine recommendations, infection control precautions, and postexposure management.
News of deadly new strains of influenza, such as the bird flu is a

worldwide concern. This course describes seasonal and avian influenza, suggests how to recognize flu, and presents facts about prevention and treatment of both bird flu and the more certain
occurrence of seasonal flu.


This course is designed to help assistants prevent work-related

pain and injuries. Learn anatomy and mechanisms of microtrauma
affecting the assistant. Discover how body mechanics, positioning, instruments and operatory layouts can affect your musculoskeletal health. Pros and cons of assisting stool features, as well
as proper stool adjustment will be discussed. Learn how strong
postural muscles help protect the back, and the importance of
chairside stretching to prevent muscle imbalances.
Not All Face Masks Are Created Equal

What Is Best forYou
Not all face masks are created equal. Many factors should be
taken into consideration when choosing a face mask for personal
protection. This course provides important information to help
dental professionals make informed decisions.
The Ergonomics of Dental Assisting: Preventing &

Managing WorkRelated Pain

Management of HIV/AIDS Patients in Dental Practice
Since the first reported outbreaks of HIV/AIDS, great strides have

been made in the treatment of diseaserelated opportunistic infections, neoplasms and neurological disorders. Combined use

of multiple antiviral agents and preventive treatment for pregnant women has increased the number of infected persons living
longer and seeking regular dental care. Learn the consequences
of HIV/AIDS for today's modern dental practice.
Hand Hygiene for the Dental Professional

Dental healthcare workers spend a great deal
of
time performing hand hygiene procedures.
NEW
Discomfort due to skin irritation can interfere
with adherence to recommended hand hygiene practices. This
course is designed to help the dental professional understand
how to perform hand hygiene correctly, describe different types
of hand hygiene, correctly select hand hygiene products, recognize signs of skin irritation and locate reliable resources for hand
hygiene.
09

HAZARDOUS MATERIALS IN THE

DENTAL SETTING
ning with the morning meeting, cleaning and setting up the treatment room, ergonomics and motion economy, and responsibilities during procedures.
A selftest for 2 CE credits accompanies the book and will be graded
by the ADAA. A certificate of completion is provided. ADA723
Book and VHS Video
ADAA Member: $62.50 $50 :: Nonmember: $93.75 $75
FASTTRACK TRAINING:
The Basics for Dental Staff
From the American Dental Association a thorough introduction to
the dental office for new employees. The chapters cover everything from daytoday dental office tasks such as scheduling patients and working with thirdparty payers to the intricacies of
HIPAA Privacy and Security Rules. Also covers the basics of infection control, OSHA compliance and customer service. Includes
a workbook and CDROM.
Course Number: P550
CE Credits: 5 Hours
ADAA Member: $69.95 :: Nonmember: $104.95
5 CE Hours with test completion; submit testing fee with exam.
Mercury in Dentistry The Facts
Relative to both the patient and the dental team, current information
on mercury in dental restorations is summarized, with policy statements from dental organizations and government agencies.
CLINICAL ASSISTANTS

Nitrous Oxide and Oxygen Sedation: An Update

This course will teach about the desirable characteristics of nitrous oxide, indications and contraindications of N2O/O2 use as
well as facts and myths surrounding chronic exposure to nitrous
oxide, the biological effects associated with high levels of the gas,
and ways to assess and minimize trace gas contamination in an outpatient setting.
SPECIAL OFFERING
BASIC TRAINING: A Video Introduction to Dental
Assisting
This video from the American Dental AssoWHILE
SUPPLIES LAST ciation is a wonderful introduction to chairNEW LOWER
PRICING
side dental assisting. It moves through a

typical day for a chairside assistant, begin-
JUST FOR YOU

Get p re pp ed to take a na ti o na l ex am i n at i on that will
prove competency to your patients and employer that you
have the knowledge to be the best clinical assistant that
office has ever had as part of their team.
The three parts of the national exam are covered in separate courses and can be taken together or individually.
(For separate pricing and information covered see individual listing in catalog.)
0412
0613
0715
Infection Control in the Dental Office: A

Review for a National Infection Control Exam
General Chairside Assisitng: A Review for a
National Chairside Exam
Introduction to Basic Concepts in Dental
Radiography
A $214 package to members for only $159

For nonmember, a $285 value for only $240
Mark your order form 3Pack to claim your savings
CD ROM COURSES
CD ROM COURSES
CD courses are selfcontained; no workbook is needed. A printed
test is included with the course and must be returned by mail
for grading to receive credit.
Direct Restorations: The Art of Shade Selection and

Composite Layering
This informative program details the art of creating natural looking direct composite restorations by layering different opacities
and shades of composite material. It demonstrates how multiple layers of composite can be used without adding significant
time to a procedure. The course also showcases the esthetic results that can be achieved using direct restorative techniques.
Sponsored in part by an educational grant from 3M ESPE.
Course Number: CD1-03 CE Credits: 4 Hours
ORDER INFORMATION
Returns and Exchanges
If you are not completely satisfied with your ADAA continuing education product,
simply return it within 30 days, stating your reason for return and letting us know
whether you want a replacement, refund, or exchange. Materials must be received
in salable condition, and shipping must be prepaid. Upon return, an $8.00 charge
will be assessed per order for restocking and handling. On orders of three or more
courses, a charge of $11.00 will be assessed. Shipping and handling fees are nonrefundable.
If material you receive is damaged or incorrect, please contact our office within
30 days for a replacement.
Prices
All prices listed in this catalog are effective January 1, 2009. Illinois residents
must add 9% sales tax to the total amount of the order. Prices are subject to
change without notice. If this occurs, any necessary adjustments will be made
to your order.
Shipping Information
Please allow 24 weeks for normal shipment. Rush orders cannot be accepted.
Make check or money order payable to:
Clinical Procedures in Fixed Prosthodontics

This interactive learning CDROM developed by 3M ESPE takes
the dental professional stepbystep through the basics of the
crown and bridge procedure. Navigation through the programs
is by procedure: diagnosis, preparation, impression, provisional,
and final restoration. Sponsored in part by an educational grant
from 3M ESPE
Course Number: CD1-01 CE Credits: 2 Hours
Sensitivity in Dentistry
Sensitivity in dentistry is a widely discussed topic today, and this
interactive CDROM developed by 3M ESPE covers theories and
background information, diagnosing pain, postoperative sensitivity associated with direct and indirect restorations, cervical
dentin sensitivity, and sensitivity and vital tooth bleaching. This
course is recommended for the experienced assistant. Sponsored
in part by an educational grant from 3M ESPE
Course Number: CD2-01 CE Credits: T4 Hours
WEB BASED COURSES

Visit www.dentalassistant.org to take many of
these home study course offerings
at reduced online prices.
ADAA CONTINUING EDUCATION IS ONLINE!
Courses will be added online throughout

the yearso visit often.
American Dental Assistants Association

35 E. Wacker Drive, Suite 1730
Chicago, IL 60601
Attention: Division of Education
For bulk and special orders, shipping prices vary, so please call 312-541-1550
ext. 211 for a quote.
Charge your order by fax at 312-541-1496 or call 312-541-1550, ext. 211
(8:30 am4:30 pm, CT).
Foreign Orders
All foreign orders must be paid in U.S. currency. Additional shipping charges
will be applicable to destinations outside the U.S. An invoice will be sent for the
additional postage and the order will be shipped when remittance is received.
Policies
Continuing Education Credits. All ADAA courses are approved for continuing education credits by the Dental Assisting National Board and most state agencies
requiring dental assisting education. Check with your state board if you have any
questions.*
"DANB Approval" indicates that a continuing education course appears to meet
certain specifications as described in the DANB Recertification Guidelines. DANB
does not, however, endorse or recommend any particular continuing education
course and is not responsible for the quality of any course content.
The ADAA is designated as a nationally approved sponsor by the Academy of General Dentistry. The formal continuing education programs of this sponsor are
accepted by AGD for Fellowship, Mastership and membership maintenance credit.
Approval does not imply acceptance by a state or provincial board of dentistry. The
current term of approval extends from 04/10/1992 to 05/31/2011.
Tests. Only tests for courses currently produced by the ADAA are accepted for grading. Due to course revisions and updates, we recommend that the courses be completed within a year of purchase. Only the original answer sheet will be accepted for
grading (no photocopies allowed). All ADAA nonmembers must submit a test
processing fee of $10.00 with each test (no fee for ADAA members).
*Dental Practice Management courses are not approved for credit by the California
Board of Dental Examiners.
CE ORDER FORMS
Please print or type (For additional orders, please copy form)
Name _______________________________________________________ ADAA Member #________________________ c Nonmember
(Not CDA#)
Address _____________________________________________ City _________________________________ State ________ Zip _____________

Daytime telephone ( ________ )_____________________________
c Check or money order enclosed
c Visa
c MasterCard
E-mail address:_______________________________________________
Card # ________________________________ Exp. Date _____________
Name_____________________________________________ Cardholders signature _________________________________________________

Cardholders address _________________________________________ City _________________________ State ________ Zip______________
Course number
Course name
Price
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
Shipping/Handling Schedule
$0$30
$4.00
$31$50
$6.00
$51$70
$7.00
$71$99
$9.00
$100$199
$10.00
$200 and over $12.00
Subtotal
____________
Illinois residents must add 9% sales tax
____________
Shipping/handling (see chart at left)*
____________
Total amount
____________
*Bulk and Special Orders: Shipping prices vary. Please call 312-541-1550 ext. 211 for a quote.
Please allow 24 weeks for delivery. Make check or money order payable to American Dental Assistants Association, 35 E.Wacker Dr.,
Ste. 1730, Chicago, IL 60601, Attn: Div. of Education; charge your order by fax (312-541-1496); or call 312-541-1550, ext. 211 (8:30 am4:30 pm, CT).
Please print or type (For additional orders, please copy form)

Name _______________________________________________________ ADAA Member #________________________ Nonmember
(Not CDA#)
Address _____________________________________________ City _________________________________ State ________ Zip _____________

Daytime telephone ( ________ )_____________________________
E-mail address:_______________________________________________
Check or money order enclosed
Card # ________________________________ Exp. Date __________
Visa
MasterCard
Name_____________________________________________ Cardholders signature _________________________________________________

Cardholders address _________________________________________ City _________________________ State ________ Zip______________
Course number
Course name
Price
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
_______________
______________________________________________________________________________________
____________
Shipping/Handling Schedule
$0$30
$4.00
$31$50
$6.00
$51$70
$7.00
$71$99
$9.00
$100$199
$10.00
$200 and over $12.00
Subtotal
____________
Illinois residents must add 9% sales tax
____________
Shipping/handling (see chart at left)*
____________
Total amount
____________
*Bulk and Special Orders: Shipping prices vary. Please call 312-541-1550 ext. 211 for a quote.
Please allow 24 weeks for delivery. Make check or money order payable to American Dental Assistants Association, 35 E.Wacker Dr.,
Ste. 1730, Chicago, IL 60601, Attn: Div. of Education; charge your order by fax (312-541-1496); or call 312-541-1550, ext. 211 (8:30 am4:30 pm, CT).
10
FELLOWSHIP IN THE ADAA
Reach for the new National Standard of

Excellence in Dental Assisting
Thousands of dental assisting professionals have proven their skill and dedication
through earning the Certified Dental Assistant or Registered Dental Assistant credential. Now, the ADAA is offering Fellowship, a challenging path to:
Increased value to your patients and practice
Enhanced confidence in your dental assisting capabilities
Public recognition of your professional achievement
Increased professional status
Satisfaction of increased education
Building selfesteem
Patterned after the renowned recognition programs of the Academy of General
Dentistry, this recognition program encourages a higher level of skill that ultimately
benefits all the patient, the assistant and the doctor.
To become a Fellow of the ADAA, a dental assistant must hold ADAA Active membership prior to application and must accrue 300 hours of continuing education credit
after enrolling in the program.
Those who are already Certified Dental Assistants are halfway to achieving Fellowship
and automatically receive 150 hours of credit upon enrolling. (Exception: CDPMA
earns 100 points). Those holding Registered Dental Assistant status from a state may
apply for RDA credit (awarded on a statebystate basis according to established
criteria).
Upon successfully completing the Fellowship Program, enrollees are recognized at
ADAA Annual Conferences. National recognition is provided through the ADAAs professional journal, and press releases announce the awarding of the Fellowships to
hometown media and relevant professional associations.
Fellowship is a program of many benefits, not only for you, the dental assistant, but
also for the patients you serve and the doctors with whom you work. And as a certified or registered assistant, your achievements and skills are recognized and
rewarded. As the profession of dental assisting moves forward, you can move forward too. Take a step in an upward direction: Strive for higher achievement and more
recognition as you become a Fellow of the American Dental Assistants Association.
For full details and an enrollment form, call or write:

American Dental Assistants Association
35 E. Wacker Dr.
Suite 1730
Chicago, IL 60601-2211
Telephone 312-541-1550 Fax: 312-541-1496
E-mail: adaa1@aol.com
www.dentalassistant.org
11
PRESIDENTS LETTER
AMERICAN
DENTAL
ASSISTANTS
ASSOCIATION
TO:
Dental Assistants Everywhere
FROM: Stephen E. Spadaro, President
RE:
ADAA Membership, Now!
Will you please take just a moment to review the
many reasons why you should become a part of
Americans leading dental assisting professional
organization.
The list in the adjoining column is impressive,
and we hope you agree that this means your
membership grows in value along with the value
of this list.
In addition, let me add a few more reasons:
< Life, Health, Major Medical and Disability
programs are available in most states for
those who qualify.
< Free resum posting via our website.
< Only 48% of all professional member

associations provide group insurance
programs to their members.
HERE'S THE PACKAGE
Included in your dues are:
$50,000 professional dental assisting liability

insurance in your name automatically.
Credit card and signature loan programs in
most states for those who qualify.
$2,000 accidental death & dismemberment
insurance automatically.
Online employment service at
www.dentalworkers.com.
Member discounts on educational seminars
from ADAA automatically.
Discounts on home study continuing education courses automatically. NO GRADING
FEE for members.
< Only 14% provide a credit card program.
A subscription in your name to the awardwinning journal, The Dental Assistant.
< Only 30% employ staff to monitor

legislation.
Eligibility to participate in ADAA's fellowship

program.
< Only 19% offer scholarship programs.
ADAA DOES ALL OF THE ABOVE AND MORE!

I know I can count on you to stay with us. JOIN
NOW and continue the benefits and professional
support of the ADAA.
Visit our website to learn about our easy debit
payment plans and join us today.
Free continuing education in The Dental

Assistant.
Prescription discount service.
20% discount on membership in LifeLock's
identity theft protection service.
Life, Health, Major Medical & Disability
programs are available in most states for
those who qualify.
Se habla espanl.
Thank you for your attention.
The people who make dental assisting a profession!

12
MEMBERSHIP APPLICATION
2009 NEW ACTIVE MEMBER APPLICATION
Send payment to: American Dental Assistants Association

Suite 1730, 35 E. Wacker Drive, Chicago IL 60601-2211
Not valid after 12/31/09

PLEASE PRINT OR TYPE AND FILL ALL APPLICABLE SPACES
ADAA member previously? (if yes, when):_________________________________________________________________________ Date_____________________

Name ______________________________________________________________________________________________________________________________
Street Address ______________________________________________________________________________________________________
Apt. #_________
City __________________________________________________________________________________ State ____________ Zip ________________________

Business phone (_____)_____________________ Home phone (_____)___________________ Cell phone (_____)____________________ E-mail ___________________
State Dental Assistants Association (if other than the state where you live) ___________________________________________________________________
Local Dental Assistants Organization (if left blank, we will assign a local where available) _______________________________________________________
Sponsor (if any)_______________________________________________________________________________________________________________________
Please check applicable area:

Chairside
Business Assistant
Office Manager Educator
Other ______________________________
Please specify (if applicable): CDA #:_________________________ RDA #:_______________________

NOTE: By joining the ADAA, you also become a member of a state and local organization, if one exists.
Local membership will be in the same state as state membership. State/Local dues amounts are listed
opposite. This amount must be added to your ADAA dues.
MEMBERSHIP FEES
New Members joining in January through July 2009
New Members joining in August, September and October 2009
New Members joining in November and December 2009
Amount of Payment:
Amount of Payment:
Amount of Payment:
Full years dues both state and national.
125% of national dues (131.25) plus state dues
$105 plus state dues (See table for state dues)
(See table for state dues and multipy by 1.25)
Dues are paid through 12/31/09
$10 insurance charge is added
Full years dues both state and national.

$105 plus state dues (See table for state dues)
Example: National Dues:
$131.25 plus state dues: $30 X 1.25 = $168.75

Type of Payment:
Choose any payment option
Check or Credit Card for full year
If you want to pay in full:
or two Semi Annual Payments
or Direct Debit System
If you want to pay in two installments:
$52.50 . . . . . . .$________
ADAA New Active Dues (from above list) . . . . . . .$________ Choose one: Applying in January through July
Applying in August through October $62.50 . . . . . . .$________
+ Professional Liability Insurance (not optional) . . . .$10.00
Applying in November or December $52.50 . . . . . . .$________
+ State Dues (enter amount from list opposite or percentage) .$________ Plus professional liability insurance (not optional this insurance is paid IN FULL .$10.00
in the 1st installment and does NOT appear on the 2nd installment invoice)
TOTAL DUES (if paid in full) . . . . . . . . . . . . . . . . . . .$________
Plus 50% of State Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$________
Plaque $20 (optional) oak laminate & black leatherette . . .$________
Semi annual fee (does NOT appear on the 2nd invoice) . . . . . . . . . . . . . . . . . . . . . .$10.00
TOTAL DUES (if paid in installments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$_______
You will be billed for the balance of your dues 2 months prior to expiration dates
Want to arrange Direct Debit Payment for your ADAA dues? Visit our website: www.dentalassistant.org
TOTAL PAYMENT ENCLOSED $______________ Payment made by:
MASTERCARD
VISA
CHECK (payable to ADAA)
Account #_______________________________________ Exp._________

Cardholder Name _____________________________________________________ Cardholder Signature ___________________________________________
Cardholder Address_________________________________________________________________________________________________________________________
13
JOURNAL ORDER FORM

The Dental Assistant Journal
LISTING OF TOTAL STATE/LOCAL DUES

You must enter an amount in space provided under membership fees.
Alabama
$10
Alaska
$15
Arizona
$15
Arkansas
$10
California
$40
Colorado
$15
Connecticut
$18
Delaware
$ 6
Dist. of Columbia $12
Florida
$25
Georgia
$12
Hawaii
$12
Idaho
$12
Illinois
$23
Indiana
$35
Iowa
$25
Kansas
$20
Kentucky
$20
Louisiana
$12
Maine
$10
Maryland
$18
Massachusetts $20
Michigan
$40
Minnesota
$30
Mississippi
$15
Missouri
$10
Montana
$10
Nebraska
$15
Nevada
$20
New Hampshire$10
New Jersey
$20
New Mexico
$10
New York
$20
North Carolina $15
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
$15
$20
$12
$12
$20
$18
$12
$20
$25
$25
$15
$10
$24
$12
$15
$20
$10
ONLINE EMPLOYMENT PACKAGE

Looking for a job?
Seeking professionals to fill your dental team vacancies?
dentalworkers.com is the site for you!
dentalworkers.com lets you post your resum free of charge!
An on-line resum guide helps you build a professional resum that
impresses potential employers...and there are special benefits for
ADAA members who use this service too.
Journal of the American Dental Assistants Association

ISSN 1088 3886
Someone near you needs a subscription to The Dental Assistant a co-worker, your school or office library, your boss?
Were Americas leading magazine for and about professional
dental assistants. Topics covered include infection control,
business concerns of dentistry, Dental Assistant Recognition
Week, educational issues and much, much more. If youre not
a member of the ADAA who receives this publication, subscribe
now.
2009 Rates/lssues:
The Dental Assistant, the official publication of the American
Dental Assistants Association, is published bimonthly. Submitted articles are accepted and juried by the editorial review
board.
ISSUES
REGULAR RATES
January/February
One-year subscription
March/April
Dealers and Individuals
Same rate
May/June
U.S.A.
$20.00
July/August
Single copy price
$10.00
September/October
Canada and Mexico
$30.00
November/December
Other Foreign Countries
$75.00
Payable in U.S. funds. Payment required with order.

Allow 68 weeks for subscription entry and change of address.
Claims must be received within 90 days of cover date.
If youre in charge of finding the pros to fill your dental team

vacancies, become a part of the dentalworkers.com circle of
employers looking for qualified candidates in all dental assisting
positions...clinical, administrative and sales.
Take advantage of the opportunities at dentalworkers.com for a
competitive edge. Employer or employee call 877-235-9855,
email JOBS@dentalworkers.com or check out the website
at www.dentalworkers.com
Anniversary renewal
DENTAL ASSISTANT SUBSCRIPTION

Name ____________________________________________________
Address ___________________________________________________
City/State/Zip _______________________________________________
Se habla espaol!
Si usted se siente ms cmodo discutir los beneficios de la
asociacin de ADAA en espaol, llame nuestro numero
312-541-1550 extensiones 201, 211 o 213. Nuestros materiales educativos son en ingls, pero se pueden discutir en espaol. O mandenos correo electrnico a nrod@adaa1.com, srobles@adaa1.com
para educacin o iguillen@adaa1.com para beneficios de miembros.
No portion of ADAA fees is refundable or transferable.

Membership includes a subscription to The Dental Assistant, $50,000
professional liability insurance, and $2,000 accidental death and dismemberment insurance.
Membership, professional liability insurance and accidental death insurance insurance become effective following receipt and processing of
application.
Check enclosed payable to ADAA
Invoice please. (We can only invoice if this coupon is

accompanied by an educational institutions purchase order.)
VISA
MasterCard
Account #___________________________________ Exp. Date________
Cardholder Signature__________________________________________
Cardholder Name____________________________________________
Cardholder Address___________________________________________
Cardholder City/State/Zip______________________________________
14
ADAAF SPONSORS
The American Dental Assistants Association Foundation thanks the following companies and
organizations for their generous contributions that have aided in the funding of
worthwhile educational activities throughout the year.
3M ESPE
Procter & Gamble Crest OralB
Adec
Patterson Dental
American Dental Cooperative
PennWell Publishing
Benco Dental
Pentron Clinical Technologies
Biotrol International
Planmeca, Inc.
Cetylite Industries, Inc
Premier Dental Products
Colgate Oral Pharmaceuticals
Pulpdent Corporation
Crosstex International
Sci Can
Danville Engineering & Materials
SDS Kerr Corporation
Darby Dental
Septodont
DentalEZ Group
Sirona Dental Systems
Dentalworkers
ShoFu Dental Corporation
Dentsply Professional
Sonicare-Philips Oral Healthcare
Dux Dental
Sultan Healthcare, Inc
GC America, Inc
Sunstar Americas, Inc
Harry J Bosworth Company
TIDI Products
Henry Schein Dental
Tom's of Maine
Henry Schein Practice Solutions
Ultradent Products, Inc
Heraeus Kulzer, Inc
Vident
Hu-Friedy Manufacturing Company
VOCO America
Ivoclar Vivadent, Inc
Young Dental
Nash Institute for Dental Learning
Zenith Dental
OSAP
Zirc Company
Thank you
35 E. Wacker Dr.
Suite 1730
Chicago, IL 60601-2211
Telephone 312-541-1550 Fax: 312-541-1496 E-mail: adaa1@aol.com
We make dental assisting a profession

www.dentalassistant.org

American Dental Assistants Association 2009 Catalog

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

American Dental Assistants Association 2009 Catalog

Enviado por

Direitos autorais:

Formatos disponíveis

AMERICAN DENTAL

WHEN JUST GOOD

GO FOR THE BEST

The Art and Science of

The Business of Dentistry:

The Business of Dentistry: Patient

Inflammation: The Relationship

The Business of Dentistry:

Patient Care Coordinator: Are You

Xerostomia: Recognition and

Addressing Language and

Hand Hygiene for the Dental

The American Dental Assistants Association

ADAA Member: $88 :: Nonmember: $115

Alginate Impression and Diagnostic

Course Number: 0806

ADAA Member: $30 :: Nonmember: $43

Local Anesthesia in Todays Dental Practice

Air Abrasion in Dentistry

The Use of Pit and Fissure Sealants

Wired for Learning Orthodontic Basics

Course Number: 0813 CE Credits: 3 Hours

Setting it Straight Advanced Orthodontics

WORKBOOK COURSES CONTINUING EDUCATION

Maxillofacial Surgery Basics for the Dental

Course Number: 0807 CE Credits: 4 Hours

Maxillofacial Surgery Basics

Fabrication of Provisional Crowns and Bridges

Course Number: 0810 CE Credits: 3 Hours

Oral Health Maintenance of Dental Implants

Course Number: 0814

Dental Implants: A Second Chance at

The Art and Science ofTooth Whitening

Available only online at www.dentalassistant.org

Home Irrigation: An EvidenceBasedTherapy

Gingival Health Periodontal Assessment

This course focuses on the effectiveness of home irrigation as an

An introduction to finding, locating, and assessing periodontal

Course Number: 0517 CE Credits: 2 Hours

Course Number: 0605 CE Credits: 2 Hours

Diabetes and Periodontal Health

Prevention and Management of Oral

Course Number: 0801 CE Credits: 2 Hours

Oral Cancer Genetics: From Diagnosis

Osteoradionecrosis: Oral Health and

Understanding Nicotine Addiction and InterventionTechniques for the Dental Professional

Understanding Meth Mouth and Oral

Understanding the Dangers and Health

Blood Pressure Guidelines and Screening

Course Number: 0809 CE Credits: 1 Hour

Complementary and Alternative Medicine

An Introduction to the Herpes Viruses

WORKBOOK COURSES CONTINUING EDUCATION

Course Number: 0803 CE Credits: 5 Hours

Eating Disorders Understanding the Dental

Geriatric Dentistry: Reviewing for the Present,

Course Number: 0802 CE Credits: 4 Hours

SportsRelated Dental Injuries and

Current Concepts in Preventive Dentistry

Inflammation:The Relationship Between Oral

Course Number: 0804 CE Credits: 2 Hours

Importance of Oral Hygiene During Orthodontic

Xerostomia: Recognition and Management

Course Number: 0805 CE Credits: 1 Hour

Address _________________________ City _ State Zip _

Card # ____________________ Exp. Date _

Name_ Cardholders signature _____

Address _________________________ City _ State Zip _

Card # ______________________ Exp. Date

Name_ Cardholders signature _____