Finalize Your Registration Restfull Medical Billing | Dallas, TX "*" indicates required fields Are you attending in-person or virtually?* In-Person Virtual Will Your Spouse/Partner be Joining You?* Yes No Partner/Spouse First Name*Partner/Spouse Last Name*Partner/Spouse Email*Will Your Staff be Joining You?* Yes No Staff Product Quantity* Price: $1,100.00 Quantity Please enter all information for your staff below. Please note that a unique email must be provided for each person in your party. Failure to enter this information will result in an error. If you have any questions about the form, please email team@restfull.comStaff RegistrationFirst NameLast NameEmailPosition Office managerHygienistAssistantAssociate Add RemoveThis field is hidden when viewing the formFirst Name*This field is hidden when viewing the formLast Name*This field is hidden when viewing the formEmail* This field is hidden when viewing the formCvent IDThis field is hidden when viewing the formAdmission Item IDThis field is hidden when viewing the formReg Type IDThis field is hidden when viewing the formPartner Admission IDThis field is hidden when viewing the formPartner Reg Type IDThis field is hidden when viewing the formStaff Admission IDThis field is hidden when viewing the formStaff Reg Type IDDental License #*AGD #*Phone*Referred ByAddress Information* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Consent*Cancellation Policy: If you cancel within one week of registration, you will not be charged. All cancellations made beyond 7 days of registration will receive a credit towards a future course within ONE calendar year. In the event Restfull decides to, or is forced to cancel this event due to COVID-19 related circumstances, your card will not be charged. Video Release: I grant permission to Restfull to use any video footage from this event, including any video testimonials I record, in their marketing materials. By clicking 'Submit', you agree to Restfull’s Terms of Use and Privacy Policy. You consent to receive phone calls and SMS messages from Restfull to provide updates and information regarding your business with Restfull. Message frequency may vary. Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more information. See our Privacy Policy. I have read and agree to the following terms:*Doctor TicketCoupon Total Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
