Select Module 4 Option. For Details Read The Brochure
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Please Select
Module 4 Option A - May 7-10 (Wed-Sat)
Module 4 Option B - June 15-18 (Sun-Wed)
Modules 1 - 3 Only No Live Patient
Client Details
Tell us a bit about yourself
Legal Name (as it appears on your license)
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First Name
Last Name
Preferred Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Date of Birth (mm/dd/yyyy)
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Month
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Day
Year
Date
Dental License (State, Number)
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Practice Name & Address (Owner or Associate)
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AGD Number (optional)
Dietary Restrictions
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T-shirt Size - XS, S, M, L, XL
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Scrub Sizes - Top/Bottom (XS, S, M, L, XL)
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Instagram Handle
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Tell us about your previous continuing education background.
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How would you describe yourself as an implantologist? Beginner, Intermediate, or Advanced.
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Additional information: You may qualify for program discount. Are you a Kois Dentist? Are you a recent grad (3 years or less, Class of 2021 or later)? If yes, which year? Have you taken IA courses before? We will verify your info and apply discount.
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