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Association of Dental Anaesthetists
Safety for All
Making Dental Sedation and Anaesthesia Safe in Every Environment

*Registration:
ADA membership fee: £20.00
ADA renewal fee: £20.00
Personal Information
 
*E-Mail:Valid e-mail is required
*TitleDr/Mr/Mrs/Ms
*First Name:
*Last Name:
*Address Line 1:
Address Line 2:
*City:
*Postcode:
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*Phone:
 
*Post held: Dentist/Anaesthetist/GP/Other (Please specify)
GMC Number:
*Dietry Requirements
 
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*Card Number:No dashes or spaces please
*Expiration Month:From your card
*Expiration Year:From your card
*Security Code:
Cardholders Name
*CC Postcode
*CC Statement Address
Please note that the Association of Dental Anaesthetists accepts no responsibility for any damage caused to you, your property (computer based or otherwise), software or data caused as a result of using this payment form.
Notice of cancellation must be given in writing to ADA. All refunds are made at the discretion of ADA.
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