D5: Absorbable PDO Threads & Kybella Training
Please enter your full name and degree as you would like to appear on your completion certificate. Example: Dr. John M. Smith or John Smith, DDS
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Trinidad and Tobago
Bosnia and Herzegovina
United Arab Emirates
Papua New Guinea
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Sao Tome and Principe
United Republic of Tanzania
Country / Region
State License #
Select the course date you wish to attend:
October 18th, 2019 – Miami, FL
January 17th, 2020 – Miami, FL
April 3th, 2020 – Miami, FL
July 24th, 2020 – Miami, FL
Included with Registration:
- Complete Lecture Presentations
- Training Materials
- Continental Breakfast and Lunch
Enter Promotion Code for Tuition Discount
(Discount will not appear online now, however it will be applied when processed. Note: Only one discount per registration)
Would you like to bring a staff member to attend the program with you?
Yes I will bring a staff member - $250
Not Bringing Staff - $0
Staff Name (if bringing)
Please provide name of your staff member
Important Patient Information - Please Read
In order to ensure we have the right candidates for treatments, we will be providing patients for all clinical training participants. If you have someone you would like us to consider, please let us know ASAP and provide 3 non-smiling photos from 3 angles (front and both 45 degree sides). All patients must be approved to ensure they are qualified candidates for the treatments we are performing in this training.
You can email the 3 photos to firstname.lastname@example.org
I will be bring a model patient with me
Please provide me a patient (no additional cost)
Patient Name (if bringing)
Please provide the name of your patient for the clinical
Any Additional Information? (food allergies, special accommodations, etc.)
Billing Information - When you click submit, you will be taken to our online payment portal.
Please note that payment for the course must be made in full at least 2 weeks prior to the course date. We can accommodate special billing requests (payment plan, etc.) for your convenience.
****Unless otherwise instructed here, any balance will be processed two weeks prior to the course date****
Special Instructions for billing, if any:
Terms and Conditions
Please read completely
I understand that, once registered, I am reserving one of a limited number of spaces in a DentaSpa training course and that my reservation may prevent another practitioner from participating in the course. As such, I understand that to avoid a $299 Rescheduling Fee, I am responsible for determining my availablity in advance and will advise DentaSpa within three (3) calendar weeks of the course date if I am unable to attend and need to reschedule. As class sizes are limited and my cancellation may cause DentaSpa Seminars harm, I understand that DentaSpa offers rescheduling, but no refunds. My signature also guarantees that I will take it upon myself to ensure that the procedures being taught are legally permitted in my state of licensure under my Board's current laws and legislation.
I understand that I have the option to print this form, sign, and fax to (305) 938-5018. By submitting online, I am authorizing DentaSpa Seminars to process my registration for the selected course(s).
By checking this box, I am signifying that I have read and understand these terms and conditions.
Please type in your full name to act as your signature in full agreement with these terms and conditions.