EmailMe Form - D4: Advanced Lip & Perioral Rejuvenation

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 *

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Cell Phone *

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Email *

Confirm Email

State License # *

Specialty

Please Select Clinical Date: *

Included with Registration:

-Comprehensive Clinical Training Manual with Complete Printed Lectures
-Certificate of Course Completion
-CE Verification (Nationally Recognized by AGD PACE / ADA CERP / State Dental Boards)
-Breakfast & Lunch
-A model patient for if needed, in any city, at no additional charge
-Access to the online portal to watch the didactic lectures for 1 month post training
-Lectures will be made available 3 weeks prior to your clinical date once registration is fully paid

* Clinical Product included for all Class Package Memberships

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? *

Observing Staff - $450

Not Bringing Staff

Staff Member Name (if bringing)

How did you hear about us?

Instagram Handle

Please select which representative assisted you:

Important Patient Information - Please Read

Please check your confirmation email with further details on patient information

Patient Information *

I will bring a Lips treatment model

Please provide me a Lips treatments model

Undecided (I will update 2 weeks prior to the clinical date)

Email us at info@dentaspa-seminars.com to update your patient information.

Patient's 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.

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 in order to accommodate your attendance, any remaining tuition balance will be charged 3 weeks to the course date. You will receive

****Unless otherwise instructed here, any remaining balance will be processed 3 weeks prior to the course date****

Special Billing Requests, 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 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). 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. *