Pre Register form - Camarlengo Dental Institute

Pre-Register Form

IDR Lecture-Workshop 3-Day Course

Name *

Last Name *

What name would you like on your name badge? *

Organization/Business

Mailing Address *

City *

State *

ZIP *

Office Telephone *

Mobile Telephone *

Email Address *

Course Name	Course Start Date	Fee	Total
IDR LECTURE-WORKSHOP 3-DAY COURSE	TO BE DETERMINED	$ 4,500.00	$ 4,500.00
		GRAND TOTAL	$ 4,500.00

Food Restrictions *

Allergies *

Notes *

What is your Clinical Specialty? *

How many implants have you placed? *

How Did You Hear About This Event? *

Terms and Conditions:

Camarlengo Dental Institute reserves the right to refuse registration and to cancel or modify the conference without prior notice.

Customer Travel Costs: Camarlengo Dental Institute is not responsible for reimbursing prepaid (including non-refundable) customer travel costs. It is recommended that participants who elect to incur travel costs for a training course, schedule and purchase airfare and hotel accommodations with this in mind.

Policy Agreement *

We are committed to protecting your privacy at Camarlengo Dental Institute. We will not collect any personal information from you that you do not volunteer, and we are the sole owner of all information collected on this site. We do not sell, share, or rent this information to others in any way that we have not mentioned in this statement.

By submitting your Registration you accept our Terms & Privacy Policy.

BY FILLING OUT THIS REGISTRATION FORM, YOU ARE NOT ENROLLED IN THIS COURSE. NOR WILL PAYMENT BE RECEIVED UNTIL FIRST YOUR REGISTRATION REQUEST IS REVIEWED AND AN ACADEMIC INTERVIEW IS SCHEDULED WITH OUR DIRECTOR TO GO OVER YOUR SURGICAL SKILLSET LEVEL AND COURSE CRITERIA.

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Pre-Register Form

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