Practice Buyers Seminar registration form

Please note that all fields are compulsory and that your registration will not be processed until payment is received.

Course and practice details

Date / location:
Principal dentist's first name:
Principal dentist's last name:
Practice:

 

Address and contact details

Country:
Address:
Suburb:
State:
Postcode:
Telephone:
Fax:
Email address:

 

Attendance

Number of dentists registered with DJS Practice Sales Service:
Number of dentists not registered with DJS Practice Sales Service:
Number of non-dentist partners attending with a dentist:

 

Payment details

 

How did you hear about us

 

Free monthly e-newsletter subscription

Please check this box if you would like to be subscribed to Prime Practice's E-Newsletter (only for registrations that include an email address).

 

Terms and conditions

To avoid disappointment, please do not book travel and or accommodation until your registration is confirmed by Prime Practice. By completing this form, you acknowledge that when you register yourself or team members to attend a workshop, Prime incurs certain costs (printing, catering etc.) If someone does not turn up to a workshop they are registered for, Prime Practice will charge $50 per person per day cancellation/no show fee. To avoid this fee you must cancel your registration in writing 7 days before an event.

I have read and acknowledged my agreement to these terms and conditions.

 

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