EmailMe Form - D4: Lip Augmentation & PRP Aesthetics

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

Office Phone *

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

Cell Phone *

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

Email *

Confirm Email

State License # *

Specialty

Select the course date you wish to attend: *

October 19-20 ’19 - Miami FL

April 4-5 '20 - Miami, FL

Included with 2-Day, $2950 Registration:

- Complete Lecture Presentations & Training Materials
- Breakfast and Lunch (Both Saturday & Sunday)
- Certificate of course completion - 16 CE (ADA CERP & AGD PACE Recognized)

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)

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

Both Days - $425

Saturday Lecture - $250

Not Bringing Staff

Staff Member Name (if bringing)

Important Patient Information - Please Read

Sunday will be all day hands-on and this will be the only day you will need to bring your patient(s). All participants will be a lip augmentation case and if requested, a PRP case. We will have various products available that can be purchased during the class depending on the diagnosis of your patient. Our PRP expert will also be there and can spend more time showing the process including blood draw until the point of injection. All patients will fill out dermal filler consents forms in addition to medical history forms prior to procedures.

If you are wanting to bring your own patient, please use these guidelines when selecting your model patient or patients:

- Someone who would like to enhance or add overall volume to their lips
- Someone who has lip lines or asymmetries to their lips
- Someone who has lost the border of their lips or would like to establish more definition to this border
- Someone who has dropped corners of their mouth

We will be sending you pre-treatment instructions that you need to provide to your patients at least 48 hours prior to the day of treatment. If we are providing a patient for you, we will be providing your patient this information. We will also be providing this information during the course, however, it is important they also get it prior in preparation as may patients are on daily medications and/or supplements that may make them NOT ideal patients for injections. Patients who bruise easily because of medications that act as blood thinners or other disease processes may not be good candidates.

Even though treatments with Botox and dermal fillers are minimally invasive procedures, patients should know bruising and swelling is normal post treatment. Model patients should not have any important work or personal events coming up within two weeks of treatment.

Patient Information *

I will be bringing my own patient on Sunday

Please provide me a patient for no additional cost

Patient Name (if bringing)

Additional Costs:

Dermal Fillers: We will have various filler products available that can be purchased during the class depending on the diagnosis of your patient. If you are participating in the PRP and Micro-Needdling training, a partial, minimal supply fee of $68 will be added when you check out during the training.

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 the week prior to the course. We can do special billing requests (payment plan, etc.) for your added convenience.

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 $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. As class sizes are limited and my cancellation may cause DentaSpa Seminars harm, I understand that DentaSpa offers rescheduling, but 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. *