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.
Type a question

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

MonthDayYear
Date
Credit Card

VisaMaster Card
Name on Card
Card Number
Exp. Date

MonthDayYear
Date
Signature
Date

MonthDayYear
Date
The Advanced Dental Implant Institute Presents:

The Puerto Rico MaxiCourse@ Program

Clinical Residency in Implant Dentistry
PROFESSIONAL PROFILE
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

MonthDayYear
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
Are you interested in applying for the IV Sedation license?

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
Should be Empty:

PROFESSIONAL PROFILE