The Texas Center

Name*

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

Area CodePhone Number
Primary Contact Preference

EmailPhone
Type of Practice*

EndodonticGeneral DentistryOral & Maxillofacial SurgeryOral PathologyOrthodonticPediatricPeriodonticProsthodonticOther
Where did you graduate?
Year graduated?
Are you a doctor or staff member?*
If you are a staff member, please let us know your position?

AdministrativeDental AssistantsDental Laboratory TechnicianHygienistOther

Tuition

Doctor Registration$1,200.00

Staff Registration$550.00

Enter coupon

Subtotal $0.00Tax $0.00Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Cancellation & Refund Policy*

I have read and agreed policy: Notification of cancellation must be submitted in writing to The Texas Center via kathy@txcos.com. A $50.00 administrative fee will be withheld on cancellations postmarked on or before October 15th. Refunds are not possible after this date. If you are registered for the meeting and do not attend, you will not be provided a refund for not attending.
How did you hear about us?*
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