D1: Botox & Dermal Filler Dental Training
16 CE Credits (ADA CERP & AGD PACE Recognized)
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
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 #
Please include degree such as DDS or DMD
Are you an AGD Member? If yes, what is your Member #?
Please Select the 16 CE Course:
June 22-23, 2019 - San Francisco, CA
August 17-18, 2019 - Atlanta, GA
September 14-15, 2019 - Chicago, IL
November 23-24, 2019 - New York, NY
December 14-15, 2019 - Miami, FL
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)
I will bring a Botox patient. Please provide a Dermal Filler patient
I will bring a Dermal Filler patient. Please provide a Botox patient
Patient(s) Name (if bringing)
2-Day Course Tuition: $3250, including:
- Botox units for use to treat a model patient during the Day 2 Clinical
- Complete Botox and Dermal Filler Lecture Presentations & Training Manual
- Breakfast & Lunch (Both Days)
- All Day 2 Clinical Supplies
- Certificate of Course Completion - 16 CE (ADA CERP & AGD PACE Recognized)
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 - $275
Day 1 Lecture & Day 2 Clinical - $450
Not Bringing Staff
Staff Member Name (if bringing)
Any Additional Information? (Food allergies, Special accommodations, etc.)
Billing Information - When you click submit, you will be taken to our online payment portal.
*Payment for the course must be made in full prior to the course date. You can register for the course with a $1000 deposit.
Special Instructions for billing, if any:
Terms & Conditions:
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. 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).
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.