Joint Application for
Table Clinic/ Case Display Presentations
2009 IAO Annual Meeting
Seelbach Hilton Hotel
Louisville, Kentucky U.S.A.

 

Name:   
Address: 
Address: 
City:  
State/Province: Zip/Postal:  
Country:  
Phone (Business):
Fax Number: 
E-mail Address:
Graduate of: 
Grad. Year & Degree: 
      Circle One: General Dentist        Pediatric Dentist        Orthodontist Specialist
I Will Present a Table Clinic YES   NO
      Title of clinic:
      Summary:
      A/V (no projectors):
I Will Present a Case Display YES   NO
      Title of Case:
      Diagnosis:
      Treatment Plan:
      Treatment Time:
      Results:
      Complications:
      A/V (no projectors):

PLEASE RETURN TO IAO HEADQUARTERS
 750 N Lincoln Memorial Dr., #422  Milwaukee, WI 53202 U.S.A.
Fax: +414.272.2754