REGISTRATION - Arkansas State Dental Hygienists` Association

TEAM UP
FOR
SUCCESS
ANNUAL SCIENTIFIC SESSION
APRIL 17-18, 2015 • STATEHOUSE CONVENTION CENTER
LITTLE ROCK, ARKANSAS
MESSAGE FROM THE PRESIDENT
I am very excited about the upcoming 2015 ASDA Annual Session and would like to take this opportunity to
invite you to join us as we “Team Up for Success”. The conference will be held at the Statehouse Convention
Center in Little Rock, Arkansas, April 17 - 18, 2015.
This year marks the 128th Annual Scientific Session. The CE Committee as well as the ASDA staff has been
diligently and creatively putting together some new features for this year’s agenda. In addition to our wonderful
educational offerings, we have a great line up of networking activities, including a lunch for all conference
attendees on Friday in the Exhibit Hall with the vendors. We also will have a Vendor Appreciation Breakfast on
Saturday morning in the Marriott hotel (adjoining the Convention Center).
Our new CE Chair, Dr. Jordan Cooper has led the charge to “bring back the fun” by putting together an ASDA
Conference Party on Friday, April 17th. The party is scheduled at PROST (next to Willy D’s) in the River Market
area from 7 p.m. until 11p.m. Please mark this on your calendar as a “must attend event”. We want you to have
a festive time with your colleagues, staff and peers.
Dr. Drew Toole
Heading up the line up of our featured Keynote Speakers is Gene St. Louis presenting on Friday with topics on “Turning Potential into
Production” and “Building the Dream Practice.” Andrea Kowalczyk will also be a featured speaker on Friday and is sponsored by the Arkansas
State Dental Hygienists’ Association. Ms. Kowalczyk’s presentation will focus on “An Ounce of Prevention: Becoming a More Prevention
Centered Practice”. Additionally, on Friday, there will be a great opportunity to earn CE credit by attending special courses offered by a select
group of sponsored vendors.
Dr. Hassan Bashiri and Dr. Bryan Whitaker will be featured speakers on Saturday morning. In addition, an Infection Control course will also
be offered. To round out our agenda, we will have the ASDA Presidents’ Lunch.
I want to encourage you to register you and your staff for this very important education development conference. We need to all join together
and strive for continued personal and professional growth in events of this kind. We will have a lot of fun while learning information and
techniques for our profession.
I look forward to seeing you in April.
– Dr. Drew Toole
HOTEL INFORMATION
ROOM RATES:
Single - $154
Double - $154
Triple - $164
Quad - $174
ASDA ANNUAL SESSION HOST HOTEL
Little Rock Marriott Hotel
#3 Statehouse Plaza
Little Rock, AR 72201
http://www.marriott.com/hotels/travel/litpb-little-rock-marriott/
Reservations:
(877) 759-6290
(Make sure to notify the
hotel that you are part
of the ASDA room block!)
CUT-OFF DATE FOR ASDA ROOM BLOCK IS MARCH 17, 2015
ITINERARY
Thursday, April 16th Little Rock Statehouse Convention Center
7:00 am – 8:00 pmExhibitor Move-In
4:00 pm – 9:00 pm
Executive Council Meeting
7:00 pm – 10:00 pm
Delta Dental Meeting
Friday, April 17tH
Little Rock Statehouse Convention Center
7:00 am – 4:00 pm Registration
7:00 am – 8:30 am
ASDA General Assembly & Breakfast - ASDA Members ONLY (RSVP Required)
8:30 am – 5:00 pmExhibits Open
8:30 am – 12:00 pmGene St. Louis
“Turning Your Potential Into Production”
8:30 am – 12:00 pm
Andrea Kowalczyk, RDH, BS (Ticketed Event)
“An Ounce of Prevention: Becoming A More Prevention Centered Practice”
Sponsored by Arkansas State Dental Hygienists’ Association
8:30 am – 12:00 pm
10:00 am – 10:30 am
12:00 pm – 1:30 pm
Vendor CE Presentations
Exhibit Showcase Break
Exhibit Hall Lunch - All Conference Attendees Invited (RSVP Required)
Sponsored by Delta Dental
12:00 pm – 1:30 pm
Arkansas State Dental Hygienists’ Association Luncheon (Ticketed Event)
1:30 pm – 4:30 pm
Gene St. Louis
“Building the Ideal Practice with your Dream Team”
1:30 pm – 4:30 pm
Andrea Kowalczyk, RDH, BS (Ticketed Event)
“An Ounce of Prevention: Becoming A More Prevention Centered Practice”
Sponsored by Arkansas State Dental Hygienists’ Association
1:30 pm – 4:30 pm
Vendor CE Presentations
1:00 pm – 3:00 pmTable Clinics
3:00 pm – 3:30 pm
Exhibit Showcase Break
4:30 pm AR Society of Pediatric Dentists
5:00 pm – 6:30 pm
Pierre Fauchard Academy Reception
5:30 pm – 7:00 pmUT Reception
5:30 pm – 7:00 pmLSU Reception
7:00 pm – 11:00 pm
ASDA Party – PROST (Next to Willy D’s) All Conference Attendees Invited
Saturday, April 18th Little Rock Marriott
7:00 am – 8:30 am
ICD Business Meeting
ICD/ACD Breakfast
ACD Business Meeting
7:00 am – 8:30 am
Vendor Appreciation Breakfast - Dentists only (RSVP required)
7:00 am – 11:00 amRegistration
7:45 am – 8:30 am
ARDPAC Meeting/Breakfast
8:30 am – 10:00 am
Infection Control (Ticketed Event)
8:30 am – 10:00 am
Dr. Hassan Bashiri
“Maxillofacial Reconstruction and Rehabilitation for Head and Neck Cancer Patients, Cleft Lip and
Palate and Craniofacial Anomalies”
10:00 am – 10:30 amMorning Break
10:30 am – 12:00 pm
Steven B. Whitaker, D.D.S.
“Two Weeks of Slapped Cheeks: A Primer on Childhood Exanthems”
12:00 pm – 1:30 pm
1:30 pm ASDA Presidents’ Luncheon (Ticketed Event)
ASDA Executive Council Meeting
2015 SPEAKERS
Gene St. Louis
Steven B. Whitaker, D.D.S.
Gene St. Louis is Executive Vice President of
Practice Solutions at McKenzie Management.
For over 30 years, Gene has devoted her entire
professional career to dentistry and practice
management. She held both clinical and
administrative positions, prior to becoming a
practice management consultant in 1993.
Gene founded her own practice management
company and built it into a successful firm with
hundreds of clients nationwide. She has written
many informative articles have been featured
in a variety of dental publications. She has
written and copy wrote two manuals, one on clinical education and one
on administrative. Gene has also been a speaker for the nation’s top dental
meetings and has lectured to dental societies, dental schools, study clubs,
and state dental associations throughout the United States and Canada.
McKenzie Management is a full service, in-office dental management
company. Their clients include thousands of dental practices throughout the
U.S and Canada.
Andrea Kowalczyk, RDH, BS
Andrea Kowalczyk, RDH,BS received her A.S. in
Dental Hygiene from Brevard College in Cocoa,
FL, and her B.S. in Oral Health Promotion at
O’Hehir University. She holds a post graduate
certificate in Dental Hygiene Mentoring from
O’Hehir University. She is a member of the
American Academy of Dental Hygiene, The
American Dental Hygiene Association, the Texas
Dental Hygiene Association, and the National
Dental Practice Based Research Network.
Andrea’s background as a Dental Hygiene
Mentor for a large dental group has allowed
her to create and present continuing education
courses for dental professionals. Andrea has a special interest in assessing a
patient’s unique risk of developing dental decay, and has written articles on
the subject.
Andrea was selected to participate in the American Dental Partners
Leadership Institute, an intensive four year leadership development
program, and was named the 2011 National Dental Hygiene Leader of the
Year at American Dental Partners.
Andrea is certified by the American Academy of Dental Hygiene as an
independent CE provider. Her articles have appeared in “Dental Practice
Management”, “Efficiency in Group Practice”, RDH, Modern Hygienist, and
First Impressions magazines.
A native Texan, Andrea lives in Houston with her husband and son.
In addition to family time, she enjoys reading history and biographies,
gardening, and traveling. Andrea has this to say about her approach to
hygiene coaching: “I believe that hygienists who are properly educated,
equipped and engaged give the best patient care. My goal is to ensure the
hygienists I coach are all of these things.”
An Arkansas native, Dr. Whitaker was raised in
Fort Smith and matriculated with a bachelor’s
degree in Zoology from the University of
Arkansas in 1985. He obtained his dental
degree from the University of Missouri (KC)
and subsequently completed two dental
specialty programs, both in Georgia. In 1992
he finished a three-year residency in Oral
and Maxillofacial Pathology at the Emory
University School of Medicine in Atlanta. After
a brief career in full-time academia, he received
Endodontic specialty certification at
the Medical College of Georgia in Augusta.
Dr. Whitaker has served as president of the Northwest District Dental
Society, Arkansas Association of Endodontists and Academy of
Interdisciplinary Dentofacial Therapy. He also had the opportunity to
direct the Arkansas Department of Health’s Office of Oral Health and sit
on the American Dental Association’s Council on Scientific Affairs. He is
a diplomate of the American Board of Oral and Maxillofacial Pathology,
fellow of the American Academy of Oral and Maxillofacial Pathology,
and a specialist member of the American Association of Endodontists.
In addition, Dr. Whitaker is a fellow of the Pierre Fauchard Academy,
Academy of Dentistry International, American College of Dentists and
International College of Dentists. Teaching remains a strong interest both in
and outside of formal education and Dr. Whitaker maintains appointments
at Georgia Regents University and the University of Arkansas for Medical
Sciences. Dr. Whitaker and his wife Carol live in Fayetteville. Their three daughters
are currently attending to their studies in college or professional school
working towards careers in the music industry and medicine respectively.
Dr. Hassan Bashiri
Dr. Hassan Bashiri is the former Director and
Assistant Professor of the Maxillofacial Division
of Otolaryngology and Maxillofacial Surgery at
UAMS and has since retired from that position. He is currently the Director of the Dental
Clinic of CARTI. In the past, Dr. Bashiri was a
consultant to the VA and the Children’s Hospital
Dental Clinic. He has authored chapters in
dental and medical books, scientific dental
and medical articles related to his work and
lectured at numerous dental and medical society
meetings, both nationally and internationally.
Education: DMD degree from Tehran University School of Dental
Medicine; certificate in Prosthodontics from University of Illinois, Chicago,
IL; Masters Degree from University of Illinois, Chicago, IL; certificate in
Maxillofacial Prosthodontics from University of Pittsburg, PA.
Professional Affiliations: American Dental Association, Arkansas Central
District Association, Arkansas State Dental Association, American
Academy of Maxillofacial Prosthodontics, American Academy of
Otolaryngology and Maxillofacial Surgery, American Academy of
Cleft Lip and Palate, Member of Arkansas Mission of Mercy (served on
Prosthodontics Team at LAMOM AND WIMON) and serves in Harmony
Clinic in Little Rock, AR.
DENTIST REGISTRATION FORM
D E N T IS T REGISTRATION
ASDA 2015 ANNUAL SCIENTIFIC SESSION
__________________________________________________________________________
(Please Print Clearly) Dentist’s Name ___________________________________________________________
Full Name and Title for Badge ______________________________________________
Address ________________________________________________________________
City _______________________________________ State __________ Zip __________
Phone _______________________ E-mail _____________________________________
(Please Provide for Further Contact)
__________________________________________________________________________
DEADLINE TO PRE-REGISTER: March 27, 2015
ASDA MEMBER
PRE-REGISTERED ----------------------------------------------------------------------ON-SITE REGISTRATION -----------------------------------------------------------------RETIRED ASDA MEMBER (Must be Completely Retired from Dentistry) Pre-Registered
On-Site
$275.00 _____
$325.00 _____
☐ $130.00
☐ $160.00
PLEASE RSVP FOR THE FOLLOWING:
☐ Attending ASDA General Assembly & Breakfast (ASDA Members Only) - F r id a y , A p r il 1 7 th – 7 : 0 0 a m t o 8 : 3 0 a m
☐ Attending Exhibit Hall Lunch (All Conference Attendees Invited) – F r i d a y , A p r i l 1 7 th – 1 2 : 0 0 p m t o 1 : 3 0 p m
☐ Attending Vendor Appreciation Breakfast – LR Marriott (Dentist’s Only) - S a t u r d a y , A p r il 1 8 th – 7 : 0 0 a m t o 8 : 3 0 a m
FEES
ADA OUT-OF STATE MEMBER/FOREIGN DENTIST
NON-ADA/ASDA MEMBER
DENTAL STUDENT/FIRST YEAR GRADUATE
PRE-REGISTRATION
☐ $365.00
☐ $565.00
☐ NO FEE
ON-SITE
☐ $415.00
☐ $615.00
☐ NO FEE
TICKETED EVENTS:
ANDREA KOWALCZYK, RDH BS (Presenter for ASDHA CE Course)
INFECTION CONTROL COURSE
ASDA PRESIDENTS’ LUNCHEON
☐ $40.00
☐ $65.00
☐ $40.00
☐ N/A
☐ N/A
☐ N/A
TOTAL
$____________
_________________________________________________________________________________
PAYMENT INFORMATION:
☐ CHECK ENCLOSED (PLEASE MAKE CHECK PAYABLE TO ASDA)
☐ CREDIT CARD INFORMATION PROVIDED
CREDIT CARD INFORMATION:
CARD TYPE:
☐ VISA
☐ MASTERCARD
☐AMERICAN EXPRESS
☐ DISCOVER
CARD NUMBER: _______________________________ EXP. DATE: ________ SECURITY CODE: ________
CARDHOLDER: ________________________________ SIGNATURE: ___________________________
BILLING ADDRESS: _________________________________________________________________
CITY: ______________________________________ STATE: ___________ ZIP: ________________
RETURN COMPLETED REGISTRATION AND PAYMENT TO:
Angela Rogers Group w P.O. Box 1958 w Little Rock, AR 72203
or Register Online at www.arkansasdentistry.org
NO REFUNDS AFTER MARCH 27, 2015
PLEASE MAIL COMPLETED FORM AND
PAYMENT TO:
ANGELA ROGERS GROUP
P.O. BOX 1958
LITTLE ROCK, AR 72203
or FAX TO:
ANGELA ROGERS GROUP
ATTN: ANNE BAKER
(501) 835-3311
HYGIENIST REGISTRATION FORM
HYGIENIST REGISTRATION
ASDA 2015 ANNUAL SCIENTIFIC SESSION
________________________________________________________________________
(Please Print Clearly) N a m e ___________________________________________________________________
☐ ASDHA Member
☐ Non-Member
E m p l o y e r / P r a c t i c e N a m e ___________________________________________________
N a m e t o P r i n t o n B a d g e ___________________________________________________
A d d r e s s ________________________________________________________________
C i t y _______________________________________ S t a t e __________ Z i p __________
P h o n e _______________________ E - m a i l _____________________________________
(Please Provide for Further Contact)
________________________________________________________________________
DEADLINE TO PRE-REGISTER: March 27, 2015
ALL MEETING PASS
PRE-REGISTERED ---------------------------------------------------------------------ON-SITE REGISTRATION -----------------------------------------------------------------HYGIENE STUDENTS/FIRST YEAR GRADUATES (ALL MEETING PASS)
$95.00 _______
$115.00 ______
PRE-REGISTERED ---------------------------------------------------------------------ON-SITE REGISTRATION -----------------------------------------------------------------PLEASE RSVP FOR THE FOLLOWING:
NO FEE
NO FEE
☐ Attending Exhibit Hall Lunch (All Conference Attendees Invited) – F r i d a y , A p r i l 1 7 t h – 1 2 : 0 0 p m t o 1 : 3 0 p m
T IC K E T E D E V E N T S (A Ticketed Event is an Additional Charge and is NOT Included in the All Meeting Pass):
ANDREA KOWALCZYK, RDH BS (Presenter for Arkansas State Dental Hygienists’ Association CE Course) ☐ $40.00
ANDREA KOWALCZYK, RDH BS – HYGIENE STUDENTS
☐ NO FEE
ASDHA BUSINESS LUNCHEON (Ticket Must be Purchased at the Fee Below to Attend)
ASDHA MEMBER
☐ $15.00
NON-MEMBER
☐ $30.00
INFECTION CONTROL COURSE
☐ $65.00
ASDA PRESIDENTS’ LUNCHEON
☐ $40.00
TOTAL
$___________
______________________________________________________________________________
PAYMENT INFORMATION:
☐ CHECK ENCLOSED (PLEASE MAKE CHECK PAYABLE TO ASDA)
☐ CREDIT CARD INFORMATION PROVIDED
CREDIT CARD INFORMATION:
CARD TYPE:
☐ VISA
☐ MASTERCARD
☐AMERICAN EXPRESS
☐ DISCOVER
CARD NUMBER: _______________________________ EXP. DATE: ________ SECURITY CODE: ________
CARDHOLDER: ________________________________ SIGNATURE: ___________________________
BILLING ADDRESS: _________________________________________________________________
CITY: ______________________________________ STATE: ___________ ZIP: ________________
RETURN COMPLETED REGISTRATION AND PAYMENT TO:
Angela Rogers Group w P.O. Box 1958 w Little Rock, AR 72203
or Register Online at www.arkansasdentistry.org
NO REFUNDS AFTER MARCH 27, 2015
PLEASE MAIL COMPLETED FORM AND
PAYMENT TO:
ANGELA ROGERS GROUP
P.O. BOX 1958
LITTLE ROCK, AR 72203
or FAX TO:
ANGELA ROGERS GROUP
ATTN: ANNE BAKER
(501) 835-3311
ASSISTANT / STAFF REGISTRATION FORM
ASSISTANT/STAFF REGISTRATION
ASDA 2015 ANNUAL SCIENTIFIC SESSION
________________________________________________________________________
(Please Print Clearly) N a m e ___________________________________________________________________
☐ Assistant
☐ Staff/Clerical
E m p l o y e r / P r a c t i c e N a m e ___________________________________________________
N a m e t o P r i n t o n B a d g e ___________________________________________________
A d d r e s s ________________________________________________________________
C i t y _______________________________________ S t a t e __________ Z i p __________
P h o n e _______________________ E - m a i l _____________________________________
(Please Provide for Further Contact)
________________________________________________________________________
DEADLINE TO PRE-REGISTER: March 27, 2015
ASDA MEMBER – STAFF REGISTRATION (ALL MEETING PASS)
PRE-REGISTERED ---------------------------------------------------------------------ON-SITE REGISTRATION ------------------------------------------------------------------
$95.00 _______
$115.00 ______
NON-ASDA MEMBER – STAFF REGISTRATION
PRE-REGISTERED ---------------------------------------------------------------------ON-SITE REGISTRATION ------------------------------------------------------------------
$190.00 ______
$270.00 ______
PLEASE RSVP FOR THE FOLLOWING:
☐ Attending Exhibit Hall Lunch (All Conference Attendees Invited) – F r i d a y , A p r i l 1 7 t h – 1 2 : 0 0 p m t o 1 : 3 0 p m
TICKETED EVENTS:
ANDREA KOWALCZYK, RDH BS (Presenter for Arkansas State Dental Hygienists’ Association CE Course) ☐ $40.00
INFECTION CONTROL COURSE
☐ $65.00
ASDA PRESIDENTS’ LUNCHEON
☐ $40.00
TOTAL
$____________
______________________________________________________________________________
PAYMENT INFORMATION:
☐ CHECK ENCLOSED (PLEASE MAKE CHECK PAYABLE TO ASDA)
☐ CREDIT CARD INFORMATION PROVIDED
CREDIT CARD INFORMATION:
CARD TYPE:
☐ VISA
☐ MASTERCARD
☐AMERICAN EXPRESS
☐ DISCOVER
CARD NUMBER: _______________________________ EXP. DATE: ________ SECURITY CODE: ________
CARDHOLDER: ________________________________ SIGNATURE: ___________________________
BILLING ADDRESS: _________________________________________________________________
CITY: ______________________________________ STATE: ___________ ZIP: ________________
RETURN COMPLETED REGISTRATION AND PAYMENT TO:
Angela Rogers Group w P.O. Box 1958 w Little Rock, AR 72203
or Register Online at www.arkansasdentistry.org
NO REFUNDS AFTER MARCH 27, 2015
PLEASE MAIL COMPLETED FORM AND
PAYMENT TO:
ANGELA ROGERS GROUP
P.O. BOX 1958
LITTLE ROCK, AR 72203
or FAX TO:
ANGELA ROGERS GROUP
ATTN: ANNE BAKER
(501) 835-3311
ANNUAL SESSION SPONSORS
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ASDA is bringing back the fun!
All conference attendees are invited to join us
for drinks and dancing at PROST (next to Willy D’s)!
Friday, April 17th | 7:00 pm – 11:00 pm
Non-Profit
U.S. Postage
PAID
Permit No. 1068
Little Rock, AR
7480 HWY. 107
SHERWOOD, AR 72120
SAVE THE
DATE!
ASDA ANNUAL SCIENTIFIC SESSION • APRIL 17-18, 2015
Register Now at arkansasdentistry.org