Member Paid - Wellness Dentistry Network

MEMBERSHIP FLUENT FORM PAID

First Name

Last Name

Practice Name

Country

Practice Street Address

Practice Address, Suite/Unit Number

Practice City

State

Province / Territory

Zip Code / Postcode

Practice Website

Where did you hear about us?

Referral

Webinar/Conference Name

Practice Phone

Practice Mobile Phone

Desired Team Admin Name

Desired Team Admin Title/Credentials

Desired Team Admin Email

Four Additional Team Members To Receive WDN Access

What’s your top priority for your membership?

Access to cutting-edge, personalized resources and tools to enhance patient care.

Opportunities for advanced education and training, including live webinars on oral-systemic health.

Took a course by Dr. Thompson and want to implement his protocol into our practice.

Increasing practice revenue.

Networking with like-minded dental professionals committed to wellness dentistry.

Practical strategies and protocols to implement evidence-based care.

Other (please provide details below)

Other

Signature

Sign Here

Name	Domain	Purpose	Expiry	Type
Google Maps	wellnessdentistrynetwork.com	This is an integrated map service.	1 day	HTTP
reCaptcha	wellnessdentistrynetwork.com	This is a service that checks whether data is entered by a human or by an automated program.	1 day	HTTP
YouTube Video	wellnessdentistrynetwork.com	This is a video player service. It can be used by user to watch, like, share, comment and upload videos.	1 day	HTTP
Google Tag Manager	wellnessdentistrynetwork.com	This is a tag management system. Via Google Tag Manager, tags can be integrated centrally via a user interface. Tags are small sections of code that can track activities. Script codes of other tools are integrated via the Google Tag Manager. The Tag Manager allows to control when a particular tag is triggered.	1 day	HTTP