Oral Health Day at the Capitol on April 6, 2023 in Carson City

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* 1. Name

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* 2. Credentials

DMD

DDS

Student

Other (please specify)

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* 3. Cell Phone

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* 4. Email

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* 5. Practice Address

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* 6. Practices City and Zip Code

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* 7. Type of Practice

Sole Dentist Practice

Small Group Practice

Large Group Practice

N/A

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* 8. Please select which activities you will participate in (please select all possible activities):

Starts at 9am - Welcome and Orientation, Legislature 101, Association Policy Update

Starts at 11am - Legislator Meetings

Starts at 5pm Legislator Reception (location to be within walking distance of Capital building)

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* 9. For Meetings with Legislators, do you prefer morning or afternoon Legislator Meetings?

Morning

Afternoon

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* 10. Do you have a relationship with a Nevada legislator? Please add their name below as we will try to pair you with that legislator for one of the meetings.

Oral Health Day at the Capitol on April 6, 2023 in Carson City

Question Title

* 1. Name

Question Title

* 2. Credentials

Question Title

* 3. Cell Phone

Question Title

* 4. Email

Question Title

* 5. Practice Address

Question Title

* 6. Practices City and Zip Code

Question Title

* 7. Type of Practice

Question Title

* 8. Please select which activities you will participate in (please select all possible activities):

Question Title

* 9. For Meetings with Legislators, do you prefer morning or afternoon Legislator Meetings?

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* 10. Do you have a relationship with a Nevada legislator? Please add their name below as we will try to pair you with that legislator for one of the meetings.

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* 11. Statehouse Tour – afternoon only

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* 12. We will add you to the Oral Health Day distribution list and update you as we move closer to April 6th.