Directory Registration

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Directory Registration

    All doctors with a special interest in treating implant patients are encouraged to submit their practice information. Directory listing is free unless you desire your home page listed. The fee for a home page link is $50 US per year payable by credit card only. Should you desire a link, simply fill out the URL location and credit card information below. Advisor positions may be limited by geographical area. Please apply early if you desire to be an advisor. To ensure proper listing, please complete all information.

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Your Name:

Speciality:

Phone:

E-Mail:

Street Address:

Second Street Address:

City:

State/Province:

ZIP/Postal-Code:

Country:

Would you like to be a WCDI Advisor? Yes No

Would you like to be notified of changes to WCDI? Yes No

Please list my home page. All information must be provided. $50 US per year fee. You may also FAX or call your request to 800-484-6006 Ext. 1483

My URL is:

Credit Card Type:

Name On Card:

Expiration Date:

Card Number:


Submit Directory Information

(send the form) (clear and start over)

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