EmailMe Form - D3: Regenerative Aesthetics: PRF & PRF Gel

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 *

Confirm Email

State License # *

Specialty

Please select the 12 CE course you wish to attend: *

Sun, October 12th - Miami, FL

Sat, November 12th - Miami, FL (IAFA Symposium)

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)

Patient Need *

I will bring a PRF patient to the clinical

I will need a PRF patient provided for me

Patient Member Name (if bringing)

Included with $1895 Course Tuition:

-Comprehensive Clinical Training Manual with Printed Lectures
-Certificate of Course Completion
-CE Verification (Nationally Recognized by AGD PACE / ADA CERP / State Dental Boards)
-Breakfast & Lunch
-A model patient for both Botox & Fillers if needed, in any city, at no additional charge
* Clinical Product included for all Class Package Memberships

* CE is 4 Hours – online at your leisure, 8 Hours – Hands on Clinical

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

Both Days - $450

Not Bringing Staff

Staff Member Name (if bringing)

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, payment for the course must be made in full at least 1 month prior to the course date.

****Unless otherwise instructed here, any balance will be processed 1 month 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). *

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. *