OHIO DENTAL PROVIDER TRAINING ON TOBACCO CESSATION COUNSELING
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Please use the below form to register with us so that we can serve your continuing education needs better!
(Please allow 48 business hours for completion. Also note that the registration email will come from no-reply@editmysite.com which may go to your spam folder.)
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Name
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First
Last
Primary Email
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Secondary Email
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Phone Number
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Primary Organization
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Secondary Organization
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Profession
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Dentist
Dental Hygienist
Registered Dental Hygienist (RDH)
Dental Assistant
EFDA
Office Personnel (Front Desk, Office Manager, Other)
Other (please note below if Other)
Dental Student
If you selected "Other" for profession, please enter a description below:
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What percentage of patients in your practice receive Medicaid services?
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Less than 30%
30% or more
Has your practice already billed for Tobacco Cessation Counseling services using procedure code D1320?
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No
Yes
Not Sure
Business Address
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Questions or Comments:
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