2026 Live Surgical Course Registration Form

Name*

First NameLast Name

E-mail*

example@example.com

Office Number*

Mobile Number*

Company*

Office Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any Dietary restrictions or allergies?*

YESNo

If yes please explain

Do you plan to bring an assistant(s) with you? (additional fee)*

YESNO

If "yes" how many assistants will you be bringing? (if you wish to bring more than 3 please email)

123

Assistant Name 1

First NameLast Name

Assistant 1 Cell Phone Number

Please enter a valid phone number.

Assistant Name 2

First NameLast Name

Assistant 2 Cell Phone Number

Please enter a valid phone number.

Assistant Name 3

First NameLast Name

Assistant 3 Cell Phone Number

Please enter a valid phone number.

Appointment*

Please note: there is a 5,000 non-refundable deposit. It can be transferred to another course.

Advanced Surgery- Operator

$30,000.00 Quantity

Basic Surgery-Operator

$25,000.00 Quantity

Advanced Deposit ONLY This is a deposit only, the remaining is due 2 weeks prior to the start of the course. NO ACCEPTIONS

$5,000.00 Quantity

Surgical Assistant Tuition

$1,500.00 Quantity

ObserverLecture, Hands on, Observing surgeries.

$3,000.00 Quantity

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human*