EmailMe Form - D2: Level 2 Botox & Dermal Filler Dental 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: John A. Smith, DDS

Office Address *

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

Phone *

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Cell Phone *

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Email *

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State License # *

Specialty

What year did you attend a Level 1 Botox & Filler training?

Which training academy did you attend for your level 1 Botox & Filler training?

Please select the 16 CE course you wish to attend: *

February 24-25, 2024 - Miami, FL

July 20-21, 2024 - Miami, FL

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)

Included with $3650 Course Tuition:

- Up to $400 in Botox units for the Day 2 Hands-on clinical
- Complete Advanced Lecture Presentation Materials
- Breakfast & Lunch Included Both days
- Before/After pictures of your model patient
- Certificate of course completion - 16 CE (ADA CERP & AGD PACE Recognized)

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

Both Days - $650

Saturday Lecture Only - $450

Not Bringing Staff

Staff Member Name (if bringing)

How did you hear about us?

Instagram Handle

Please select which representative assisted you:

Patient Information:

Sunday will be the full day hands-on clinical and the only day you will need a patient(s).

ALL patients must be approved in order to ensure they are qualified candidates for advanced treatments. Choose to either bring a model patient, or we can provide a volunteer model at no additional charge. If you would like us to provide a qualified model, please let us know ASAP or no later than 2 weeks prior to course date.

If you are planning to bring a model patient, please e-mail a non-smiling picture of your patient to ana@dentaspa-seminars.com

Second-Day Hands-On Clinical *

I will bring a model patient with me and will submit a picture for prior approval

Undecided (must let us know 2 weeks prior)

Please provide a volunteer model patient (no additional charge)

Patient Name (if bringing)

Additional Costs and Product Needs:

Because we are doing more extreme makeovers on patients, participants will be doing several Botox and dermal filler treatments that require more product. For this reason, we give participants the option to work with a partner so they can do all the procedures but share costs of product with a partner participant

DentaSpa will provide the Botox units for clinical (up to 50 units included). Students may choose to buy additional units for practice at cost ($6.01 per unit). However, this is optional because the Botox units included with registration are sufficient to cover all the areas we are doing during the clinical.

Facial sculpting patients will typically require a minimum of 2 syringes with a volumizing filler such as Restylane Lyft, Voluma or Contour. Depending on the brand you choose, the prices range from $235-$400 per syringe.

An Evaluation will be sent prior to the course. There are varying factors that will determine the amount of dermal filler product needed, including: Partnering, bringing your own patient, and the treatments you are comfortable with.

Would you like to partner with another doctor or work on your own? *

I would like to partner with another doctor and share the cost of materials

I would prefer to work alone

Any Additional Information? (food allergies, special accommodations, name of your patient(s), 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 DentaSpa incurs logistics costs for each registrant, I understand that DentaSpa offers rescheduling, however 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. *