World Clinical Laser Institute

Seminar Registration
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Seminar:
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Titles (DDS,DMD,etc.):
Position:
**State Dental License:**
Practice Name:
Special Food Request:
If you have been working with a Biolase Laser Specialist, please provide their name:



Laser Ownership
Do you own a laser?:
Yes No If yes, please list:

Referral
How did you hear about the Seminar?:
Sales Mailer Online Other:



Additional Attendees  
1. Attendee Name:
2. Attendee Name:
3. Attendee Name:
4. Attendee Name:
5. Attendee Name:
6. Attendee Name:



Tuition and Fees
**All payments are in US dollars.

Total Number of Attendees:
   
 
Note: For no cost events we will not charge your credit card, but require valid credit card information for registration.


Comments


Before continuing, please confirm that WCLI has permission to charge your credit card for the WCLI Seminar.

All information will be sent through a SECURED CONNECTION and to a SECURED SERVER. Please click the 'Submit' button below. The information will be sent to our registration staff, who will email or fax your confirmation form. Thank you for registering for the World Clinical Laser Institute's Seminars.

NOTICE: Patient Protection and Affordable Care Act
Effective August 1, 2013, the World Clinical Laser and Imaging Institute and BIOLASE, core sponsor of the WCLI, is required to operate under full compliance of Section 6002 (the "Sunshine Act") of the Patient Protection and Affordable Care Act ("Affordable Care Act"), which requires all medical device manufacturers to report to the U.S. Department of Health and Human Services regarding any "transfers of value" to covered recipients, which include customers or prospective customers of BIOLASE, that may occur within a calendar year. These transfers of value may include gifts, meals, or travel, as well as financial compensation of any kind.

The Secretary of the Department of Health & Human Services will make the reported information available through a searchable web site beginning in 2014. To read the final ruling of the Affordable Care Act in its entirety, you may visit the U.S. Department of Health and Human Services web site and to read the final ruling on implementation of the Sunshine Act you may visit http://federalregister.gov/a/2013-02572.

*(By Clicking Submit Below) You have read and understood the notice on the Patient Protection and Affordable Care Act. 

By clicking submit you are verifying all information provided is accurate. You will be taken to the checkout and providing billing information authorizing WCLI to charge for your registration fees for the Seminar. *