Please complete the SDS Registration Form for the person who is attending the course or subscribing to Online Dental Consulting Service.
  • To pay by credit card, complete the form then click the 'Send' button at bottom of form.
  • To pay by check or Money Order made out to Specialty Dental Services:
    • 1) Complete the form and click the 'Print' button at bottom of form;
    2) Once completed form has printed, click the 'Send' button at bottom of form;
    3) Mail completed form and check to Specialty Dental Services, P.O. 258 Portersville, PA 16051-0258
    Contact Information
    First Name: *
    Middle Name:
    Last Name: *
    Title: *
    Dental Specialty: *
    Practice/Organization: *
    Street Address 1: *
    Street Address 2:
    City: *
    State: *
    Zip/Postal Code: *
    Primary Phone: * ()-
    FAX: ()-
    E-mail Address:
    Web Site:

    Please select a course/session:
    SDS Courses
    Course Name Date Length Comments
    Online Dental Consulting Service From Today 3 Months
    Online Dental Consulting Service From Today 6 Months Save $25!
    Online Dental Consulting Service From Today 12 Months Save $100!
    Professional Information
    Dental License Number:
    State:
    Only Licensed Professionals have access to clinical database. Licensing information is verified to ensure Specialty Dental Services is publishing web sites for only licensed professionals.


    Billing Information
    Referral Code:
    (Referral discount applies to SDS courses only, not Online Dental Consulting Services)
    Billing Total: *
    Pay by Check/Money Order:
    Credit Card: *
    Cardholder Name: *
    Card Number: *
    Expiration Date: * (Month-2 digits)  (Year-4 digits)
    Shipping Information
    Will download course materials. No shipping required.
    Shipping address is the same as the address in the Contact Information section (above).
    Street Address 1: **
    Street Address 2:
    City: **
    State: **
    Zip/Postal Code: **
    *required fields
    **required if course materials need to be shipped