Brighter way Registration - Learn new skills and techniques while provding services to those in need - AIE

Learn new skills and techniques while provding services to those in need

Please fill out the form below to register for an AIE/Brighterway course and one of our representatives will get in touch with you shortly. This form is essential to custom tailoring our live surgery experience to your needs.

NOTE: Arizona state board requires your state board to send license verification. This process may take 4-6 weeks.

Full name*

Suffix*

What type of dentist are you?*

Dental license #*

State of licensure*

Address*

Apartment/Suite

City*

State*

Zip Code*

Country*

E-mail*

Confirm E-mail*

Office Phone Number*

Mobile Phone Number*

Approximate no. of hours implant surgical didactic CE completed*

Are you currently restoring implants?*

Have you attended a hands on surgical implant course before?*

Have you attended a live surgical course before?*

How many implants have you placed in the last year?*

What size scrubs do you wear?*

What scrubs type?*

What glove size do you wear?*

Latex Allergy?*

How did you hear about us?*

If you selected Other above, please specify.

Do you have any dietary restrictions? If yes, please describe.

If you selected Other above, please specify which techniques.

If you selected Other above, please specify which devices.