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Professional Custom Fields

(Clinician) State of Licensure

Are you licensed in MA or VT?

Neither MA nor VT

Profession

Straumann customer number

State License Number

State of Licensure

Straumann customer #

NPI Number

State License #

Are you an AGD Member?

Yes

AGD Number

NPI #

As part of being a speaker or instructor for Straumann Group my email address will be displayed on assigned course registration pages as a means of contact for registrants and participants.

I agree.

Pursuant to VT Prescribed Products Law – Gift Ban: Straumann, as a medical device manufacturer is prohibited from providing meals to clinicians with an active VT dental license.

If I participate in a CE Course which includes a meal and I consume the meal I agree to be invoiced for the cost.

I confirm that I will not partake in any meals provided and I will make my own arrangements for food.

GDC Number

NTF Number

RPPS - France

Ma Profession

BIG-Nummer

First Name

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An automatic confirmation email has been sent to the email address below. To complete your registration, please click on the link in the confirmation email.

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Professional Custom Fields

Business Registration

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THANK YOU!