Course Registration Form

Register for your Course

Fill out the form carefully for registration
Attendee Name*

First NamePreferred/Nick nameLast Name
Birth Date

MonthDayYear
Phone Number*
Email*
example@example.com
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Manager's First and Last Name
Office Manager's Email
Desired Course and Date *
Dental License Information

We'll request your Colorado Temp Dental License
Dental License Number*
Dental License Type
DMD or DDS
Date License was Issued*

MonthDayYear
Date
License Status*
State License was issued*
If you have an ADG number please list it below
Help us make your CSI experience even cooler
Do you have any dietary restrictions?*
What types of snacks do you like?
What is your favorite caffeinated beverage?
What size of scrub top do you wear?*

XSSMLXLXXLOther
What size of TShirt do you wear?*

XSSMLXLXXLOther
Are you bringing any team members with you? ($1200 per DA)*
If Yes, what is their name and do they have any dietary restrictions?
What is your dominate Hand*
What should we know to help your experience be more pleasant?
We'll just need a copy of your Malpractice Insurance and your Dental License.

A quick photo with your phone will be perfect. If you do not have them you can send them to Info@coloradosugical.com before the course starts
Malpractice

Cancelof
Dental License

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How did you hear about Colorado Surgical Institute?*
Additional Comments
By checking this box, you consent to receive text messages from Colorado Surgical Institute (CSI) regarding course updates, reminders, and other relevant communications.

Text me!

Select Your Course and Add-Ons*

Course DepositHold your seat with a deposit. Our team will reach out shortly to complete your registration and finalize your payment plan.

$5,000.00 Quantity
Item subtotal:$0.00

Total

$0.00

Credit Card

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Register for your Course

Dental License Information

Help us make your CSI experience even cooler

We'll just need a copy of your Malpractice Insurance and your Dental License.

Credit Card