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”

                           ISMD REGISTRATION FORM
               
COURSE:   ___PERIODONTAL MEDICINE I
                   ___PERIODONTAL MEDICINE II (Level I Pre-requisite)
                   ___DENTAL MEDICINE
DATE: (MM/DD/YEAR)_____________
LOCATION: ___________________________________________________________

PRACTICE (PLEASE PRINT!)
DOCTOR______________________________________________________________
Address _______________________________________________________________
City/State/Zip___________________________________________________________
Phone_____________________________ Phone (cell)__________________________

REGISTRANTS AND TUITION [NOTE: CUT-OFF DATE OCCURS 30 DAYS PRIOR TO COURSE]
     REGISTRANTS (LIST NAMES)                TUITION:                BEFORE                    ON/AFTER
                                                                                                       CUT-OFF DATE      CUT-OFF DATE
1. Doctor listed above                                             ---                         □ 695                     □ 795
2. Additional Doctor _______________________________              □ 695                     □ 795
3. Staff Name/ Position _____________________________              □ 695                     □ 795
4. Staff Name/ Position _____________________________              □ 695                     □ 795
5. Staff Name/ Position _____________________________              □ 695                     □ 795
                                                                                         TOTALS     _________       
REGISTRATION [NOTE: MONIES WILL NOT BE DEPOSITED UNTIL CUT-OFF DATE]
□ Mail to above address with check
□ Fax with credit card information (to 1-908-464-1137)
     Credit Card Type: □ VISA □ MASTERCARD
     Name (As it appears on the card): ________________________________________
     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:

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 8/1/2009 to 7/31/2011”.
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. A refund minus $100 will be refunded or applied as per your directions.

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.