EmailMe Form - D1: Botox & Dermal Filler Dental Training

Attendee Name *

Prefix First Last Suffix

Diploma Name

Please enter your full name and degree as you would like to appear on your completion certificate. Example: Dr. John M. Smith or Jane Smith, DDS

Office Address *

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

Office Phone: *

### - ### - ####

Cell Phone: *

### - ### - ####

E-mail *

Confirm E-mail

Web Site

State License # *

Active License is required to attend course

Licensed State *

Dental Specialty

Please include degree such as DDS or DMD

Please Select A Course: *

April 20-21, 2024 - Gainesville (UF Course)

May 4-5, 2024 - Phoenix

June 8-9, 2024 - NYC

August 10-11, 2024 - Atlanta (21 CE)

September 7-8, 2024 - Kansas City (20 CE)

October 5-6 , 2024 - Miami

November 23-24, 2024 - NYC

December 7-8, 2024 - San Juan, PR

Live Patient Clinical (Day 2 Only) *

I will bring a model patient with me for BOTH Botox & Dermal Fillers

Please provide me with a model patient for both Botox & Dermal Fillers (No additional charge)

Undecided (must update within 2 weeks of course date)

Patients should be willing to have both Botox and dermal filler treatments.

Patient(s) Name (if bringing)

2-Day Course Tuition: $3650, including:

- Comprehensive Clinical Training Manual with Complete Botulinum Toxin & Dermal Filler Lecture Presentations
- All Clinical supplies for Sunday (*Clinical products not included)
- Certificate & Verification of Course Completion (16 CE credits – AGD PACE / ADA CERP Recognized)
- Breakfast & Lunch included both days
- Choose to either bring a model patient, or a model patient will be provided for you

Enter Promotion Code for Tuition Discount (only 1 per registration)

Would you like to bring a staff member to attend the program with you? *

Day 1 Lecture & Day 2 Clinical Observation - $650

Day 1 Lecture only - $450

Day 2 Clinical Observation only - $450

Not Bringing Staff

Staff Member Name (if bringing)

How did you hear about us? *

Instagram Handle

Please select which representative assisted you: *

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 any balance payment for the course will be charged 3 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 three weeks prior to the course date****

Special Instructions for billing, if any:

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 three (3) calendar weeks of the course date if I am unable to attend and need to reschedule. Since class sizes are purposely kept small to ensure individualized instruction for optimal learning and DentaSpa incurs costs per registrant, I understand that DentaSpa offers rescheduling, but no refunds. My signature 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. My signature also guarantees that I am currently a licensed dental practitioner in good-standing with my state of licensure.

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.

Terms & Conditions:

Please type in your full name to act as your signature in full agreement with these terms and conditions. *