www.hivdent.org
www.HIVdent.org

Registry
to receive Updates and Mailings

HIVDENT IS INTENDED TO SERVE AS A MEANS OF ACCESSING INFORMATION FROM AUTHORITIES IN THE FIELD OF ORAL HEALTH CARE FOR PEOPLE LIVING WITH HIV, AS WELL AS EDUCATION, RESOURCES, PUBLIC POLICY AND ETHICS. HIVDENT IS INTENDED TO BE A SOURCE OF INFORMATION AND IN NO WAY SHOULD REPLACE THE CARE AND EXPERTISE PROVIDED AT THE LOCAL LEVEL.

Your Name:
Your Email Address:
Your Mailing Address: Address Line 1
Address Line 2
City
State or Province
Country
Zip or Postal code
Telephone #s: (optional) Phone (optional)
Fax (optional)
Are you a Health Care Provider? Yes No
(if so please check the appropriate box on the right)
DDS/DMD RDH MD DO
NP PA RN LPN
Dental Assistant MSW
Other Allied Health Care Provider
Organization/ Institution (optional)
  If you are a Health Care Provider, can HIVDENT furnish your name to people living with HIV disease in your community seeking a referral? Yes No
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