Demystifying EndodonticsFebruary to October 2022 - R250 ppBook Now Select your date and venue*Cape Town (23rd February 2022)East London (24th February 2022)Johannesburg (5th May 2022)Durban (21st May 2022)Cape Town (3rd September 2022)Durban (22nd October 2022)Name* First Last HPCSA Number Phone*Email* Dietary RequirementsNo Special RequirementsHalaalKosherOtherPlease specify your dietary requirements* How would you like to pay? (Cost R250 per person)*Payment Gateway (Credit/Debit Card)Electronic Fund TransferTicket Price: How many tickets do you require?123456789102nd Ticketholder First Last 3rd Ticketholder First Last 4th Ticketholder First Last 5th Ticketholder First Last 6th Ticketholder First Last 7th Ticketholder First Last 8th Ticketholder First Last 9th Ticketholder First Last 10th Ticketholder First Last HiddenTotalTotal Please pay the total displayed above to the account below and email a proof of payment to admin@dentalwarehouse.co.za Account Name: The Dental Warehouse (Pty) Ltd Bank Name: First National Bank Branch Code: 260950 Account Number: 50370105452 Reference: Endo + City followed by your surname e.g. EndoCPTVanwyk EndoCPT – Cape Town EndoBLO – Bloemfontein EndoJHB – Johannesburg EndoEAS – East London EndoNEL – Nelspruit EndoDBN – Durban On completion of this form, you will be redirected to a payment gateway where you will be prompted to pay the amount displayed above. Once your payment has been processed, a Henry Schein representative will confirm your booking. Please fill in your billing address for payment processing purposes below.Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country In order to improve your course experience, we'd like to know a bit more about your current endo preferencesWhich file system/s are you currently using? How many endo treatments do you do on average per week? Which obturation technique are you currently using? What would you like to achieve from this course? Please note that HSDW complies with the Protection of Personal Information Act 04 of 2013 and we will only process your personal information upon your written consent. Kindly therefore note that the information you provide in this form shall be used to obtain CPD points on your behalf, in which case we shall delete it as soon as you have received your CPD certificate, unless we already prior consent or lawful purpose to process the information. Kindly tick the boxes below if you do not consent for us to further process the information for: - Marketing of products and providing information related to you profession field of practice, The information will only be shared within HSDW group of companies and our relevant service providers who are bound my similar data privacy obligations as HSDW, and will be stored in a secure manner to prevent loss and unauthorised access or destruction. In the above cases we shall keep the information indefinitely. Please note that you may always opt out of the communications or send a notice to our deputy information officer Charles.Mandienga@henryschein.co.za to withdraw your consent and we will stop processing your information and delete same immediately, unless otherwise directed by applicable law. The below survey if intended to assist us to improve our product and service offering to you, should you have not consented for us to retain your information, please tick yes if you consent for us to retain the survey anonymously. For more information on our data privacy, please visit our privacy policy hereI consent for Henry Schein Dental Warehouse to retain information for the purposes specified. Yes No PhoneThis field is for validation purposes and should be left unchanged.
