F.I.T. Dallas Modern Implant Solutions Registration

Modern Implant Solutions

Immediate Placement & Custom Healing Techniques for Predictable Outcomes
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
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
Practice Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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?
Any special considerations needed? (i.e. Food Allergies, Learning Disabilities, etc)
How did you hear about F.I.T.?
Payment
Which Course Date Would You Like To Attend
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 $1,000. If you reschedule your registration and subsequently cancel, the $1,000 non-refundable fee will still apply, regardless of when the cancellation occurs.

Course Tuition

Modern Implant Solutions: Early Bird Pricing LIMITED TO THE FIRST 10 SPOTS

Early Bird Pricing LIMITED TO THE FIRST 10 SPOTS

$2,999.00

Modern Implant Solutions

MINEC America Education Center, 909 Lake Carolyn Pkwy #1800b, Irving, TX 75039

$3,500.00 Quantity

Total

$0.00

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Modern Implant Solutions

Attendee Information

Dental Information

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