PST Payment Form - Grad Refresher Course

Refresher Course Registration

Advanced Pinhole® Training Course - For Pinhole Graduate Clinicians ONLY
Registration Information
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Name (optional)
Office Phone Number*

Country CodeArea CodePhone Number
Office Email*
example@example.com
YesNo
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Professional Information
DDSDMDBDSOther
General DentistryPeriodonticsOral SurgeryOrthodonticsProsthodonticsOther
Licensing Information
License State and License Number
E.g. CA 000000
AGD Number
Provide your AGD number for CE credit submissions.
Course Information
August 22, 2025 FridaySeptember 26, 2025 Friday
EnglishSpanish
Course*
prevnext( X )
Pinhole® Surgical Technique Advanced Pinhole® Training Course
Include 24-month access to the self-paced course

$1,500



Non-doctor Staff Registration #1 (Optional)
Bring your staff for Pinhole training. Staff must attend with registered dentist. Up to 3 staff.

$150



Non-doctor Staff Registration #2 (Optional)
Bring your staff for Pinhole training. Staff must attend with registered dentist. Up to 3 staff.

$150



Non-doctor Staff Registration #3 (Optional)
Bring your staff for Pinhole training. Staff must attend with registered dentist. Up to 3 staff.

$150



Total

$0.00
Non-doctor Staff #1 Registration Information*

First NameMiddle NameLast NameTitle
Non-doctor Staff #2 Registration Information*

First NameMiddle NameLast NameTitle
Non-doctor Staff #3 Registration Information*

First NameMiddle NameLast NameTitle
Should be Empty:

Refresher Course Registration

Registration Information

Professional Information

Licensing Information

Course Information