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Signature Date Please return to Los Angeles Dental Society 3660 Wilshire Blvd Ste 510 Los Angeles CA 90010 Phone 213. Should cancellations occur 5 days prior to the date of the clinical course no refunds will be given. A 150 re-enrollment fee will apply to reschedule a clinical course. LOS ANGELES DENTAL SOCIETY Coronal Polishing Registration Student Name Address City State Zip Phone Cell Phone Fax Email Employing Dentist Doctor s Address Doctor s Phone Doctor s Fax Doctor s Email Schedule of...
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