Your enthusiasm makes a difference for both the dentist you referred, as well as the strength of the ADA! Please answer the questions below so that the ADA may recognize your good work.
First we need your information, then we'll ask about the dentist you recuited.
If you aren't a tripartite member, you'll have the opportunity to select the appropriate category, such as "Federal Dental Services."
If you referred more than one dentist, you'll have the opportunity to enter additional names after submitting this form.