Forms & Payment
Paid in Full - $3350.00 payment
Payment Plan $1250.00
Payment Plan $750.00
Holder in Due Course Rule applies to payments accepted by Westside Family Dentistry by the student. This includes Cash, Check or Payment Plans.
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Please complete the following to reserve a place in the next class _________________________________.
Date of Class
( ) Payment in full ($3350.00) ( ) Visa ( ) MasterCard ( ) Discover ( ) American Express
Credit Card # _________________________________________ Expiration Date ______________________________.
( ) Check Enclosed ( ) Money Order/ Cashier’s Check
Name (Print) ___________________________________________________
City____________________________________________________________ Zip Code _______________________________
Phone Number: _________________________________________________ SS# ____________________________________
Scrub Size: Top S M L XL XXL Bottom: S M L XL XXL
Signature _____________________________________________________ Date: __________________________________
This form must be submitted to:
Westside Family Dentistry
Dental Assisting School
2915 Westside Drive
Durant, OK 74701
Refunds and cancellations policy
A graduation certificate, letter of recommendation and pin will only be awarded to those students attaining a 70% will not receive a certificate but will be allowed to retake the entire course (if desired) at a reduced fee of $1800.00. A full refund will be made of all deposits or payments if cancellation is made before the start of the first class. After the first class but prior to the second class, all but $375.00 will be refunded if cancellation is made. For cancellations during class 2-5, $230.00 per session will be charged plus $375.00 for the first class and any remaining balance will be refunded. There will be no refunds after the 5th session. Those wishing to cancel for illness or personal reasons may resume their course study in the next class with no penalty and may repeat the already completed sessions if desired.
How did you find out about our course?
( ) Internet
( ) School Counselor ____________________________ (Name of School)
( ) Newspaper _____________________________ (Name of Newspaper)
( ) Former Student ______________________________ (Name of Former Student)
( ) Other ____________________________________________
Westside Family Dental Assistant School