2026 Live Surgical Course Registration Form

Name

First NameLast Name

E-mail

example@example.com

Office Number

Format: (000) 000-0000.

Mobile Number

Format: (000) 000-0000.

Company

Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dental License State and number

Date license was issued

Upload a copy of your Dental license and Malpractice Insurance

Do you have any Dietary restrictions or allergies?

If yes please explain

Do you plan to bring an assistant(s) with you? (additional fee)

If "yes" how many assistants will you be bringing? (if you wish to bring more than 3 please email)

Assistant Name 1

First NameLast Name

Assistant 1 Cell Phone Number

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

Assistant Name 2

First NameLast Name

Assistant 2 Cell Phone Number

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

Assistant Name 3

First NameLast Name

Assistant 3 Cell Phone Number

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

Course Date

Please check and acknowledge our refund policy

My Products

Advanced Surgery- Operator

$25,000.00 Quantity

Basic Surgery-Operator

$20,000.00 Quantity

Operator Deposit ONLY

This is a deposit only, the remaining is due 2 weeks prior to the start of the course. NO ACCEPTIONS

$5,000.00 Quantity

Surgical Assistant Tuition

$1,500.00 Quantity

Observer

Lecture, Hands on, Observing and assisting surgeries and deliveries

$4,995.00 Quantity

Enter coupon

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human

Live Surgical Course Registration Form

My Products*

My Products