EmailMe Form - D5: Absorbable PDO Threads & Kybella Training

Attendee Name *

Prefix First Last Suffix

Certificate Name

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

Office Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Office Phone *

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Cell Phone *

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Email *

Confirm Email

State License # *

Specialty

Select the course date you wish to attend: *

August 25th, 2023, Miami, FL

February 23rd, 2024 - Miami, FL

August 23rd, 2024 - 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 - $350

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 ana@dentaspa-seminars.com

Patient Information *

I will be bring a PDO model patient with me but need a Kybella patient

I will be bring a Kybella model patient with me but need a PDO patient

I will bring a patient for both PDO and Kybella

Please provide me a patient for both (no additional cost)

PDO Patient Name (if bringing)

Please provide the name of your patient for the clinical

Kybella 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 in order to accommodate your attendance, any remaining tuition balance will be charged 3 weeks to the course date.

****Unless otherwise instructed here, any remaining balance will be processed 3 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 $399 Rescheduling Fee, I am responsible for determining my availability in advance and will advise DentaSpa within four (4) 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). Any remaining tuition balance will be charged 3 weeks prior to the course date.

Media Release and Information Usage

This policy ensures compliance, transparency, and a valuable learning experience for our esteemed participants at DentaSpa Seminars.

During our comprehensive courses, we capture photos and videos to showcase the high-quality training, hands-on experiences, and expert guidance provided. These visuals are used across multiple marketing channels to inspire and inform dental professionals worldwide.

By completing the registration form, attendees grant consent for DentaSpa Seminars to use their likeness in promotional materials, including photos, videos, testimonials, and case studies. Participants understand the public sharing and unlimited utilization of these visuals. Personal information, such as email addresses and phone numbers, will be strictly used for internal purposes, including sharing information on advanced courses, industry updates, and exclusive offers.

DentaSpa Seminars is committed to protecting attendees' privacy and rights, adhering to applicable data protection laws. Attendees may withdraw their consent for media release and information usage by contacting our team prior to the course.

For further information, contact DentaSpa Seminars at info@dentaspa-seminars.com *

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. *