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Dental Courses | Periodontal Courses | Dental Biofilms

 
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COURSE REGISTRATION

 

 

“My sails are not filled by the favouring north winds nor is my voyage troubled by the hostile south winds.
In strength, intelligence, looks, in virtue, place and possessions, although the last of the great, I am among the first of the last.”

                                                   Horace, “Epistles”

 

 
     
 

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COURSE REGISTRATION
“Fifty-Percent Course Repeats”

2014: COURSE DATES AND LOCATIONS

□ Biofilms and Periodontal Medicine I                           
    Date: March 7 - 8, 2014 (REVISED DATE)
    Site: Manhattan (near 57th Street)
    Fee: $250     Credits: 13

□ Systemic and Functional Dentistry
   Date: April 25-26, 2014
   Site: Manhattan (near 57th Street)
   Central New Jersey
   Fee: $250    Credits: 13

□  Sign up for both courses for $400


 

 
    Scientia Est Potentia  
 

LECTURER AND                           
CONTACT PERSON:
Philip E. Memoli, DMD
438 Springfield Ave
Berkeley Heights, NJ
07922, USA

PROGRAM PROVIDER
The Institute for Systemic Medicine and Dentistry
1-888-SYS-DENT (797-3368)
systemicdentistry.org
admin@systemicdentistry.org
 
 
 

                           ISMD REGISTRATION FORM
               
COURSE:  □  Biofilms and Periodontal Medicine I
                       Date: March 7 - 8, 2014 (REVISED DATE)
                       Site: Manhattan (near 57th Street)
                       Fee: $250    Credits: 13

                  □  Systemic and Functional Dentistry
                       Date: April 25-26, 2014
                       Site: Central New Jersey
                       Fee: $250   Credits: 13

                  □  Sign up for both courses for $400

______________________________________________________________________

PRACTICE (PLEASE PRINT!)
DOCTOR______________________________________________________________
Address _______________________________________________________________
City/State/Zip___________________________________________________________
Phone_________________ Phone (cell)________________ Email __________________

REGISTRANTS AND TUITION [Note: Cut-Off Date Occurs 30 Days Prior to Course]
     REGISTRANTS (LIST NAMES)                TUITION:                                  
                                                                                                      
1. _________________________________      ________                     
2. _________________________________      ________                            
3. _________________________________      ________                           

                                                       TOTALS     _________       

REGISTRATION [NOTE: MONIES WILL NOT BE DEPOSITED UNTIL CUT-OFF DATE]
□ Mail to above address with check
□ Fax (908-464-1137) or Call (908-464-9144) with Credit Card Information
     Credit Card Type:   □ VISA   □ MASTERCARD
     Name (As it appears on the card): __________________________________________________
     Billing Address of Card: __________________________________________________________
     □ Practice Address      □ Other
     Card Number _____________________________ Exp. Date __________________

CONFIRMATION LETTER
□ Mail it to the above address
□ Fax it to me: __________________________________________________________
[NOTE: See attached Refund and Cancellation Policies]

 

 
 

CONFIRMATION:  

 


COURSE CREDIT:

 

Academy of General Dentistry

 

 

ATTENDEE
CANCELLATION AND
REFUNDS



COURSE
CANCELLATION

 

 

 

DISCLAIMER

1. Once registration and payment is received, a ‘Letter of Confirmation' will be sent with directions via the transmission you have selected.
2. If you do not receive a Letter of Confirmation within one week of submission, please call our office.

1. The Institute for Systemic Medicine and Dentistry is designated as an Approved PACE Program provider by the Academy of General Dentistry.
2. “The formal continuing education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2011 to 7/31/2013.”
3. To receive AGD Credits, Registrants must sign both an Attendance Sheet and AGD Credit Form (AGD number must be on the form) which will be forwarded directly to the AGD.
4. Attendees will receive a combined AGD Attendance Record Form and a State Dental Board Certificate with course credit breakdown, date, hours, and location for your records.

1. Attendees must cancel by faxing a “Letter of Cancellation”. This form must include your name, address, notice, and directions to either refund your money or apply it to a future course.
2. A full refund will be awarded before the cut-off date.
3. After the cutoff date, $50 will be deducted from the refund.

1. Over-registration for a course may require additional dates to be provided. Registrants who sign first have the option to select which dates are preferable for them. Every effort will be made to accommodate all registrants.
2. A full refund will be granted if the ISMD must cancel a course due to unforeseen circumstances. Attempts to contact registrants will be made immediately via the information provided on the “Registration Form”.
3. The ISMD will not be responsible for unreimbursed fees in the event of course cancellation.   

1. The ISMD is committed to presenting new concepts in the field of dentistry. Some new theories and procedures, as in all dental courses, may be deemed controversial.
2. The Program includes a section entitled “Scope of Practice”, which, among other topics, will delineate any issues the ISMD considers controversial. Specific legal questions should be directed to your attorney or State Board of Dentistry.