Location:

Date:

I learned about this course by:

My specialty is:

I would like to participate in the following level:

First Name:

Last Name:

Address:

City:

Telephone:

Zip code:

Fax:

Email:

Mobile No:

Scrub size:

Current Implant Experience

Please enclose the following:

  • Completed and Signed Registration Form
  • Deposit of $1,000 USD in the form of Credit Card, Check or Wire Transfer

Payment and Cancellation Policy:

  • All cancellations must be made in writing no later than 8 weeks prior to the original course date. Tuition is non-refundable
    after the 8 week mark, but can be transferred to another course date for up to 1 year. Postponing course less than 10 days before
    arrival may incur a hotel and clinic fee
  • Deposit of $1,000 USD is NON REFUNDABLE but can be transferred for up to 1 year.
  • Payments are due no later than 6 weeks prior to course, or upon registration, whichever comes first
  • Course dates are subject to change with prior notice from the organizer.

Required documents:

(Not due upon registration but must be submitted no later than 3 weeks prior to the course start date)

  • Copy of Passport
  • Copy of Dental License
  • Copy of Dental School Diploma
  • Copy of Curriculum Vitae (outline any implant experience)
  • Copy of recent results from Infectious Disease Testing (Hepatitis B, C and HIV )*
    *(Results can be from a lab such as Quest Diagnostic, LabCorp etc. or a letter from physician)
  • Recent picture

Payment

I am paying:


Deposit Only

In the form of:



Credit Card


Check (payable to Implantology Courses Inc and mailed to 710 W Higgins Rd Ste 102, Park Ridge IL 60068)


Wire Transfer

Signature:

Date:

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