DENTAL HYGIENIST PUBLIC DIRECTORY FORM

By filling out this form you are submitting your information to be posted publicly on our Dental Hygienist Directory. Please do not fill this form out if you are trying to access the website as logging in is no longer required for full access.

Are You an Independent Practitioner?*

YesNo

Note: this information will be shared publicly

Type(s) of Hygienist Practice*

A dental hygiene clinicA mobile dental hygienist

A dental hygienist in Residential CareIndependent

EducationResearch

Public Health

Work Category*

Clinical PracticePublic Health

EducationMobile/Residential

IndependentResearch

Administration/Other

Business Name*

Handling Emergencies

YesNo

Hygienist Name*

Address

City

Province*

Postal Code

Phone

Fax

E-mail Address*

Website

What Area(s) Do You Service?*

What is your practice anniversary date?

Additional Information

Account Registration

Username*

Password*

Confirm Password*

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