Application of Pit and Fissure Sealants/Coronal Polishing
A Certification Course for Dental Assistants
Registration Form - 8 CE Hours
A Certification Course for Dental Assistants
Registration Form - 8 CE Hours
To register please complete this registration form and return it with a current copy of CPR card and tuition to:
Pit and Fissure Sealant/Coronal Polishing Certification Course for the Dental Assistant
Professional Dental Continuing Education-Del Mar College
104 Village Path
Castroville, TX 78009
Or
E-mail: prodentalce@gmail.com
For more information call: 210-218-8730
Please use one form per person (photocopy form as needed)
Date of Course _______________________
Name ________________________________________________ Credentials (i.e.: CDA) _______________
Date of Birth__________________________________________
(c/o) Dr. _________________________________________________________________________________
Office Address & Suite No. _________________________________________________________________
City, State, Zip ___________________________________________________________________________
Office Phone ( ) ___________________________________________Office fax_____________________
Office E-Mail _______________________________________________
Participant Home Address __________________________________________________________________
City, State, Zip ___________________________________________________________________________
Home Phone ( ) ________________________________________________________________________
Home E-Mail__________________________________________________________________________
Course Fee $595 Check # ____ (Payable to Professional Dental Continuing Education)
Credit Card _____ Amount: $__________
Card # _________________________________ Exp. Date___________ CVV Code ________
Name on Card ___________________________________ Zip Code __________
Full refund of tuition will be honored if cancellation is provided three weeks prior to the course.
No refund of tuition will be honored for cancellations after the three week time.
Pit and Fissure Sealant/Coronal Polishing Certification Course for the Dental Assistant
Professional Dental Continuing Education-Del Mar College
104 Village Path
Castroville, TX 78009
Or
E-mail: prodentalce@gmail.com
For more information call: 210-218-8730
Please use one form per person (photocopy form as needed)
Date of Course _______________________
Name ________________________________________________ Credentials (i.e.: CDA) _______________
Date of Birth__________________________________________
(c/o) Dr. _________________________________________________________________________________
Office Address & Suite No. _________________________________________________________________
City, State, Zip ___________________________________________________________________________
Office Phone ( ) ___________________________________________Office fax_____________________
Office E-Mail _______________________________________________
Participant Home Address __________________________________________________________________
City, State, Zip ___________________________________________________________________________
Home Phone ( ) ________________________________________________________________________
Home E-Mail__________________________________________________________________________
Course Fee $595 Check # ____ (Payable to Professional Dental Continuing Education)
Credit Card _____ Amount: $__________
Card # _________________________________ Exp. Date___________ CVV Code ________
Name on Card ___________________________________ Zip Code __________
Full refund of tuition will be honored if cancellation is provided three weeks prior to the course.
No refund of tuition will be honored for cancellations after the three week time.