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 #
Active License is required to attend course
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:
August 14-15 '21 - Atlanta, GA (21 CE)
September 11-12 '21 - Chicago, IL
October 9-10 '21 - Miami, FL
November 20-21 '21 - New York, NY
December 11-12 '21 - Orlando, FL
January 22-23 '22 - Miami, FL
March 12-13 '22 - 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)
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: $3450, 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?
National Dental Meeting
University / Student Club
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 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:
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 $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. 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.