Registration Form
To reserve space at any of our seminars, please complete the form below.
Early registration is encouraged to ensure admission.
License #
Dentist's name
Address
City
State Zip -
Phone number - -
Dentist(s) attending
Staff attending
Total number of people attending
Event date/location
Texas CHIP / Claims Processing - 6/26/09 / San Antonio
Texas CHIP / Claims Processing - 8/28/09 / Houston
Texas CHIP / Claims Processing - 9/25/09 / El Paso
Texas CHIP / Claims Processing - 11/13/09 / Dallas
Contact name
Your e-mail address
To ensure proper seating, please tell us which seminar(s) you will be attending and the number of seats you need for each.
Texas CHIP Dental Services
Do you submit claims electronically?
Yes
No
