Register and pay for the Versah hands-on course with Dr Stavros

Delegate information:

Please fill in all the fields to ensure registration and invoice generated is accurate.

Name(Required)

Prefix First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dietary requirement(Required)

How did you hear about the course?(Required)

Dentist Practitioners (DP) number

(In order to submit points to the Dental Professions Board)

Company/Practice name to be included on tax invoice?

(If applicable)

VAT number

(If applicable)

Field of speciality(Required)

Versah Course Fee(Required)

Price:

(VAT exclusive amount)

Tax

R0.00

Total

*Kindly note American Express cards not supported

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Name

This field is for validation purposes and should be left unchanged.