Staff Registration
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Staff Seminar Registration

StopIMPORTANT NOTICE: By law, all attendees must fill out and digitally sign their own registration form.

Are you the actual attendee for this course? Registrations completed on another attendee's behalf are strictly prohibited as a digital signature is required to complete this form. It is important to understand that this digital signature is the same as an actual signature.  Just like it is against the law to physically sign someone elses name, likewise it is the same with a digital signature.  We understand this can present an inconvenience to some, so we appreciate your assistance and understanding.

     
Select a seminar date
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Dental Practice Name (*)
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Practice Email Address (*)
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Staff Member Information
Full Name (*)
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Title (*)
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Email Address (*)
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Phone Number (*)
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I agree, and it is my intent, to sign this Hybridge Standard License Agreement (the "Agreement") by clicking on the "I Agree" button below. I understand that my signing the Agreement in this fashion is the legal equivalent of having placed my handwritten signature on the Agreement. I understand and agree that by electronically signing and submitting the Agreement in this fashion I am agreeing to be bound by the terms and conditions of the Agreement and affirming to the truth of the information, including, but not limited to, the representations, warranties, acknowledgements and undertakings provided by me and contained in the Agreement.

Digital Signature of Dental Professional

Full Name (*)
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Title (*)
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Date (*)
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Hybridge Network, 111 Humboldt St., Rochester, NY, 14609

585.319.5400

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