F.I.T. Phoenix Continuum Course Registration Form

Foundational Implantology Continuum

Phoenix Course Registration
Attendee Information
Name*

First NameLast Name
Preferred Name
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Birth Date*

MonthDayYear
Which hand is your favorite?
Dental Information
Dental License Number*
State of Dental License*
Owner or Associate
Dental Practice Name
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Practice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
State Dental License *

Cancelof
Dental Malpractice Certificate of Liability*

Cancelof
Have you taken any implant courses in the past? If so, which one(s)?
whether it was an online, lecture only, hands-on live patient course, etc
I have placed this many dental implants
What implant system (if any) are you currently using?
What are the goals that you are wanting to achieve by taking this course? (answer this as thoroughly as you can so that we can address all of your objectives)
Any special considerations needed? (i.e. Food Allergies, Learning Disabilities, etc)
How did you hear about F.I.T.?
Payment
May 7, 2026 - May 10, 2026 and October 22, 2026 - October 25, 2026
By checking this box, you acknowledge and agree to the cancellation policy: Cancellations made more than 31 days prior to the scheduled course date are eligible for a full refund or can put toward a future course date. Cancellations made within 31 days of the course date will incur a non-refundable fee of $5,000. If you reschedule your registration and subsequently cancel, the $5,000 non-refundable fee will still apply, regardless of when the cancellation occurs.*

Yes, I Agree

Course Tuition*

Deposit: Foundational Implantology Continuum

Half tuition due to register. A pay link will be sent to each participant for the remaining balance of $9,250 and will be due by September 21, 2026.

$9,250.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Foundational Implantology Continuum

Attendee Information

Dental Information

Payment