By submitting this application form, I acknowledge and agree to the following:

TREATMENT UNDERSTANDING
I understand that if I qualify for the program, the following will be provided free of charge:
- Initial dental records including examination, scans, and x-rays (valued at $250)
- Implant surgery during the training program (valued at $3000 per implant)
- Associated bone/gum grafting if required
- Necessary extractions related to implant placement
- Follow-up care for the first 3 months including:
- One-week post-surgery check-up
- One-month follow-up appointment
- Three-month implant integration check
- Any reviews needed within this period if concerns arise

I acknowledge that I will be responsible for paying:
- Crown restoration fee of $3000 per implant, which must be paid upfront to secure my position in the program
- Normal fees for any preliminary dental work required before implant surgery
- Normal fees for any additional treatment not directly related to the implant surgery
- After the initial 3-month healing period, any additional maintenance or follow-up care will incur normal fees
- A 20% cancellation fee of the crown restoration fee if I withdraw or cancel my participation in the program

PROGRAM PARTICIPATION
I understand that treatment will be provided by qualified, registered dentists under specialist supervision as part of a training program at Naenae Dental Clinic on June 19th and 20th 2026

I acknowledge that:
- Not all applicants will be selected for the program
- If selected, I must be available for treatment on the specified dates
- I must attend all required appointments, including follow-up care
- Treatment plans may need to be modified based on clinical findings

CANCELLATION POLICY
I understand and agree that:
- If I withdraw or cancel my participation in the program for any reason, a 20% cancellation fee will be deducted from my crown restoration payment
- This cancellation fee applies regardless of the timing of my withdrawal or cancellation
- The remaining 80% of my crown restoration payment will be refunded using the same payment method
- The cancellation fee helps cover administrative costs, materials ordered, and scheduling impacts

COMMUNICATION CONSENT
I understand that:
- If selected, a team member will contact me to arrange appointments
- I can opt out of promotional communications at any time
- Clinical information may be shared between treating professionals

PRIVACY AND DOCUMENTATION
I agree that:
- My dental records may be used for educational purposes
- Photos and scans may be taken for treatment planning and documentation
- My privacy will be protected in accordance with relevant laws
- De-identified treatment information may be used for educational purposes

TREATMENT SUCCESS
I understand that:
- Dental implant success rates are high but not guaranteed
- My compliance with post-operative instructions is essential
- Following recommended maintenance protocols is crucial

FINANCIAL UNDERSTANDING
I acknowledge that:
- While initial records and implant surgery are free, crown restorations must be paid for upfront
- All costs for additional treatments will be clearly explained before proceeding
- Payment for any additional treatments will be required as per clinic policy
- Financial arrangements must be confirmed before treatment begins

ACKNOWLEDGMENT
- I confirm that all information provided in my application is true and correct
- I understand that providing false information may disqualify me from the program
- I acknowledge that submission of this form does not guarantee acceptance
- I agree to attend all required appointments if selected