Registration Form

To register and pay by mail, fax or over the phone, click here.
To download a PDF of this form, click here.

Name*
FirstLast
Position*
- Dentist
- Auxiliary/Hygienist/Staff
Specialty
Alumni*
- Yes
- No
Graduation Year
Phone*
Fax
Email*
Enter EmailConfirm Email
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Registering for:*
Please list the Course Title and Date of each course you are registering for. For multiple courses add on a separate line. For example:
Radiology Certification, March 1
Nitrous Oxide Certification, March 2
Multiple guests?
- Check here to register additional guests for the course(s) above
Additional guests for same course(s):
Please provide the names of each additional guest, and if they are a Dentist or Auxiliary/Hygienist/Staff. For example:
Jane Smith, dentist
John Smith, hygienest
NOTE: If you're registering multiple guests for multiple/different courses, please provide all applicable details, in the Additional Notes field below.
Tuition Specials
- Take Three, the Fourth is Free
- Senior Citizen Discount
- Recent Graduate Special
- Tufts Dental School (Current) Alumni Members
For more information about these tuition specials, click here.
Additional Notes:
Please provide any information about special needs, discounts, feedback, etc.
NOTE: If you're registering multiple guests for multiple/different courses, please provide all applicable details here, or call 617-636-6629.

Thank you for applying online!

Please call our office at 617-636-6629 with a MasterCard,

Visa or Discover Card to process your payment.

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