Online Registration Form

One To One Circle

TUITION FEE:

$8,500 Surgical attendee & your assistant attending with you

($4000 paid at time of registration. Remaining part of tuition fee to be paid 4 weeks prior to course inception)


Please note that an active unrestricted Dental License is required for the state where the course is taking place in order to perform surgery.

 

 

 

 

* I hereby register for:
November 7-9, 2019 | CORPUS CHRISTI TX
I would like to request different date, please contact me

 

PERSONAL INFORMATION:

* First Name:
* Last Name:
* Degree(s):
* Specialty:
* Years in Practice:
* Previous Surgical Implant Experience (choose one of the following)
No previous implant experience
Have placed some implants
Been placing implants for years & consider myself advanced

 

 

CONTACT INFORMATION:

PLEASE USE THE MAILING ADDRESS THAT YOU WOULD LIKE THE CE VERIFICATION LETTERS TO BE MAILED TO

* Email:
* Cell Phone:
* Work Phone:
* Street Address:
State:
* Zip Code:
* City:

 

 

OTHER INFORMATION:

* Glove Size:
Please specify if you have dietary restrictions
* How did you hear about the course?
* In a few words...What would you like to get out of this course:

 

CANCELLATION POLICY:

Refunds will be made with written notice of cancellation and must be received four weeks prior to the course inception. 

TAX DEDUCTION:

The expense of continuing education may be tax deductible.

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