Hawaiian Dental Seminar Registration Form

YES! I will be joining you for the 39th Annual Hawaiian Dental Forum. * Which week(s) will you be attending?
  Maui - Hyatt Regency Maui Resort and Spa, February 2-9, 2019
  Kauai - Grand Hyatt Kauai Resort and Spa, February 9-16, 2019
  Both Weeks
How did you learn about our program?
Doctor Information
* First Name
* Last Name
Year of Birth
* Mailing Address
* City
* State
* Zip/Postal Code
* Country
* Office Phone
* Home Phone
Cell Phone
* Email Address
Additional Attendee Names
Registration Fees (Seminar Only) Seminar fee per person IF STAYING at meeting hotel(s) AND booking hotel through Travel Leaders of Chippewa Falls
Doctor:   One Week Only - $850        Both Weeks - $1,495
Spouse:   One Week Only - $385        Both Weeks - $678
Staff (per person):   One Week Only - $385        Both Weeks - $678

Seminar fee per person IF NOT STAYING at meeting hotel(s)
Doctor:   One Week Only - $1,150       Both Weeks - $1,979
Spouse:   One Week Only - $687          Both Weeks - $1,231
Staff (per person):   One Week Only - $687          Both Weeks - $1,231

‡ NOTE:  First staff member attending without an accompanying doctor will be charged the doctor's fee.
Payment Options * Please select a payment option
     I am paying a $250 per person deposit by credit card and will pay the balance before January 17 ,2019.
   I am paying the full amount using my credit card.
   I will call you with my credit card information.
   I will be sending a check to:
Dental Seminars & Symposia, LLC
3948 West 50th Street, Suite 205
Edina, MN 55424
‡ NOTE:  After you submit this registration form please go to the "Make a Payment" page to submit your payment.
Refer a Doctor Program
If a doctor is registered for this program and refers another doctor who is attending for the first time, then both doctors will receive a $100 credit toward their registration.
Name of the doctor who referred you
* Validation Code
Enter the code you see displayed in the box above

If you have any additional questions, feel free to call our office at 952.922.1707.