Dental Assisting Institute
10-Week Dental Assistant Training Program:

Registration Forms

Payment in full with completed registration is required to secure your class seat. Class space is limited, please call to verify if space is available by emailing us at info@dai-fl.com or calling (727) 547-4899. 

Dental Assisting Institute (DAI)  courses are administered in accordance with the guidelines of the State of Florida Board of Dentistry.   DAI requires a high school diploma or GED as a prerequisite to this program. 

Class Date  Requested  


Name
Sex
Date of Birth (mmddyy)
Address, Apt #
City, State, Zip

Social Security
E-Mail
Home Phone
Cellular Phone
Employer Phone
Method of Payment (check one) Pay by check                   Pay by Credit Card 
Pay by Carecredit         DAI Financing

Full payment of $2100.00 or $700.00 (if financing) must be received to reserve class seating.  Please mail check payable to: Dental Assisting Institute, P.O. 21517, St. Petersburg, Fl 33742-1517. To pay by credit card payment through  paypal (3% processing fee will be added to tuition), select the link below.

I have read the information given above and verify the information to be correct.  If any information is falsified a certificate will not be given.  A written notice must be given to transfer to a different class or receive a refund.  I have read the procedures describing the class training program, appropriate dress, attendance and refund policies indicated above and fully understand details pertaining to prerequisites, attendance, duration of the classes, and the required fee. 

Please direct any comments or questions to Ronda Cauchon, RDH @ (727)547-4899 or email us at info@dai-fl.com

Note: For information on hotel accommodations, 
Please contact the La Quinta Inn  at (727) 545-5611 or choose their 
name to go directly to their website for reservation information. 

Map of class location. 
4326 Park Blvd, Suite C-W, Pinellas Park, Fl 33781
Office located in the Dr. Bell's Business Plaza 
Closest crossroad 43rd Street  & Park Blvd 

 
http://maps.yahoo.com/

 

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