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ADIA Membership Application

Member Information

Prefix:
*First Name:
*Last Name:
Suffix:
Designation:
Practice/Business:
*Address 1:
Address 2:
Address 3:
*City:
*State:  *Post Code:
Country:
PLEASE LEAVE COUNTRY FIELD BLANK IF YOU LIVE IN THE US
*Telephone:
*E-mail:
*Fax:
Website:

Home Address

*Address 1:
Address 2:
Address 3:
*City:
*State:  *Post Code:
Country:
PLEASE LEAVE COUNTRY FIELD BLANK IF YOU LIVE IN THE US
*Telephone:
*E-mail:
Preferred Address:

Experience in Implant Dentistry

Years in Dental Field:
*Current Position:
Doctor's Name:
License #:
Management?
Clinical?
Surgical?
Prosthetic?
Hygiene?
Certified?

Account Information

You will need to create a web login & password to activate your membership.
Password must have at least six characters and one numeric value.

*Web Login:
*Password:
*Confirm Password:

ADIA Membership
All members receive:

  • Membership Certificate suitable for framing
  • ICOI's Glossary of Implant Dentistry II
  • Monthly digital publication and E-News
  • Monthly webinars
  • TEAM Training Book
  • Availability of implant dentistry resources
  • Tuition discounts to all ADIA sponsored programs
  • Listing in the ICOI/ADIA internet membership directory
  • Ability to contribute articles, tips and cases to our newsletter

Annual Dues Membership

Please click on the Drop down Box below to choose your Member Type


As an added convenience, we accept Master Card, Visa and American Express payments.
*Name on Card:
*Card Type:
*Card Number:
*Expiration Date: