Self Service Portal

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Step 5

Create Your Profile below
Please complete all fields below to create your membership account.
If you want to check to see if you already have an account, we can check for an existing account.
Institution (or Company)
Prefix*
First Name*
Middle Name (or first initial)
Last Name*
Suffix
Degrees

add degree(s) or reset

D.D.S.
D.M.D.
B.D.S.
D.H.Sc.
D.M.Sc.
Dr.P.H.
LDH
RDH
Ph.D.
M.P.H.
M.S.
Ed.D.
A.A.

M.Sc.
GS-ED
J.D.
LHD
M.A.
M.B.A.
M.D.
M.Ed.
M.H.P.

M.H.S.
M.H.S.A.
M.M.Sc.
M.S.D.H.
A.A.S.
A.S.
B.A.
B.A.S.-D.H.
B.L.S./B.S.
B.S.

B.S.A.H.
B.B.A.
B.S.-D.H.
B.S.-D.H.E.
B.S.-G.S.
B.S.H.A.
B.S.H.E.
D.O.
B.S-P.H.

D.C.
D.V.M.
M.P.A.

Title (if applicable)
Preferred Address*
Street Line 1*
Street Line 2
City*
State,Territory,Province
Country*
Zip Code*
Phone*

Phone Extension
Email*
Repeat Email*

Create a Username & Password

Usernames must be:
1) all lowercase (email recommended)
2) 5-16 characters

In Passwords, do not use special characters such as ( ) - & @ * $ | % ~ except for underscore (_).
Username (email is suggested)*
Password*
Repeat *
Enter DENTPIN if applicable:

Demographics

Input as mm/dd/yyyy

Date of birth

Current gender identity
- Woman
- Man
- Transgender man
- Transgender woman
- Genderqueer/Gender non-conforming
- Other
- Prefer not to state

Preferred pronouns

Optional - Please indicate your race/ethnicity (as many as may apply).

Race/Ethnicity
- American Indian/Alaska Native
- Arab
- Asian
- Black/African American
- Hispanic/Latinx
- Native Hawaiian/Other Pacific Islander
- Nonresident Alien
- White/Caucasian
- Métis (Canada only)
- Multiple Visible Minority (Canada only)
- Non-Aboriginal/Non-Indigenous (Canada only)
- First Nation (Canada only)
- Inuit (Canada only)
- Not a Visible Minority (Canada only)
- Other:
- Prefer not to state

Optional - If you are of Latinx/Hispanic cultural origin, make a selection below (as many as may apply)

Latinx/Hispanic Origin
- Cuban
- Mexican, Mexican American, Chicano/Chicana
- Puerto Rican
- South or Central American
- Other Spanish culture or origin:
- Does not apply
- Prefer not to state

Professional

Status*

To meet ADA CERP reporting requirements, ADEA would like to know if you are a dentist.

Are you a Dentist?
- Yes
- No

Are you a Dental Educator?

If you are a dental educator, how many years?

Primary Discipline*

Primary Appointment*

Primary Administrative Title*

Department (Primary)*
Other Department(s) (not in list):

Privacy Settings

Online Membership Directory*
- Stay opted in
- Opt out

Please include me in emails sent by ADEA*
- Yes