Registration Information
Facially Generated Treatment Planning
To expedite the process, please register by phone at 1.866.781.0072
or fill in your answers, print out the form and fax it to 1.480.588.9072
Today's Date: Sep 07, 2010
Course Date:
October 04 - October 06
October 06 - October 08
November 08 - November 10
December 06 - December 08
December 08 - December 10
Doctor's Name:
Mailing Address:
City:
State:
Zip:
Phone:
Fax:
Formal Name of Practice:
What is your CEREC experience level?
I have completed 0 to 50 CEREC restorations
I have completed 50+ CEREC restorations
Email:
Tuition:
$4,950 for doctors
Full Name
Position
Fee
1.
2.
3.
4.
5.
6.
7.
Credit Card Payment: MasterCard - VISA - Amex
Credit Card:
Security Code:
Expiration Date:
Name on Card:
