TO ENROLL BY MAIL: Please fill in this Registration Form completely
and send in with your payment (enrollment is not compl...
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Participation/Certification Course Dentists and Dental Hygienists:A Standard Proficiency Certification Course in Laser Dentistry

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Participation/Certification Course Dentists and Dental Hygienists:A Standard Proficiency Certification Course in Laser Dentistry

  1. 1. TO ENROLL BY MAIL: Please fill in this Registration Form completely and send in with your payment (enrollment is not complete without payment) to the address below. UTHSCSA Dental School Continuing Dental Education and Alumni Affairs MSC 7930 7703 Floyd Curl Drive San Antonio, Texas 78229-3900 The University of Texas Health Science Center at San Antonio is an ADA CERP Recognized Provider TO ENROLL BY PHONE: Please Call (210) 567-3177 TO ENROLL BY FAX: Please FAX your completed registration form to (210) 567-6807 People who are hearing or speech impaired may call TTD Message-Relay Texas at (800) 735-2989 or (800)735-2988. Course Title:______________________________________________________________Course Date:__________________ Course Fee: $___________________________________J DDS J DMD J RDH J RDA J DLT J ADP Date of Birth:___________________________________ Last Name:_________________________________________________________________________________________ First Name:___________________________________________________________________________________________ Dental School :___________________________________________________Year of Graduation:______________________ Home Address:________________________________________________________________________________________ City:______________________________________________________State:________________ZIP:__________________ Office Address:___________________________________________________________Suite #:_______________________ C/O:________________________________________________________________________________________________ City:__________________________________________________________State:__________________ZIP:____________ Email Address:________________________________________________________________________________________ Office Phone:_________________________________________________________________________________________ Home Phone:_________________________________________________________________________________________ Fax No:_____________________________________________________________________________________________ Enclosed Check (Payable to UTHSCSA): J Check J Mastercard J Visa J Discover Check Number:____________________ Credit Card Number: Include 3-digit ID on back of card:________________________________________________________ Expiration Date:_______________________________________________________________________________________ Cardholder’s Name:____________________________________________________________________________________

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