Practice Transformation Masters Program Enrollment

The Communications Solution

Dentist / Practice Name

Address

City, State, Zip

Phone

Fax

E-mail address

1: Choose your program

Option A $1250/mo.* 1)Comprehensive diagnostic two-day practice visit with Sandy Roth 2) Practice assessment 3) Participation in the program 4) All learning resources 5) Monthly personal phone consultation with Sandy Roth *Sandy's travel expenses are billed separately

Option B $750/mo.* 1) Practice assessment 2) Participation in the program 3) All learning resources 4) Monthly personal phone consultation with Sandy Roth

2: Choose your payment option

A) Payment in full

VISA

American Express

MasterCard

Discover

Check - mail along with a printout of this registration

B) Monthly Automatic Charge to credit card - please call to set up the monthly schedule. (800) 848-8326.

3: Choose your start date

Summer, 2008

Fall, 2008

Register Soon - each Masters program is limited to 10 dentists. We encourage you to sign up early to insure your participation in your chosen session.

Fax: (877) 848-8325 E-mail: marybeth@prosynergy.com or sandy@prosynergy.com Phones: from North America 1-800-848-8326 1-877-491-8326 Worldwide 1-352-799-0255