reg-prof-profile

Registration Form for 2026-2027 Class

The Puerto Rico MaxiCourse® Program and Clinical Residency in Implant Dentistry

FULL NAME

Degree

License No

AGD #

State

AAID #

Mailing Address

Phone Numbers:

Office

Please enter a valid phone number.Format: (000) 000-0000.

Cellular

Please enter a valid phone number.Format: (000) 000-0000.

Home

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Total cost of tuition: $27,950.00

Payments in Full have a 7% discount (does not apply to payments with credit card)

(does not apply to payments with a credit card)

Deposit: $2,000 (non-refundable) Payment: Money Order:

Please make the check payable to Dr. José E. Pedroza.

CheckMoney Order

Check / Money Order - Number (Please make the check payable to Dr. José E. Pedroza.)

Date

The Advanced Dental Implant Institute Presents:

The Puerto Rico MaxiCourse@ Program

Clinical Residency in Implant Dentistry

Name

Billing Address

Home Address

Phone Numbers:

Home

Please enter a valid phone number.Format: (000) 000-0000.

Office

Please enter a valid phone number.Format: (000) 000-0000.

Mobile

Please enter a valid phone number.Format: (000) 000-0000.

E Mail

example@example.com

Date of Birth

Date

Place of Birth

Personal Statement

My Vision

My Goals (List the 3 most relevant to you):

1.

2.

3.

My Expectations Concerning this Course

YesNo

Professional Education and Training

Dental School

Year

Degree(s) Obtained

Other Professional Studies or Trainings (one per line)

Professional Experience (Name the last two):

Work Place 1

Position 1

Years

Work Place 2

Position 2

Years

Professional Affiliations (one per line)

Publications (one per line)

Other Interests (one per line)

Sponsored by:

The Advanced Dental Implant Institute

University of Puerto Rico - Medical Sciences Campus, Deanship For Academic Affairs

PROFESSIONAL PROFILE