Event Registration

Sign up for: 

[   ] March 29, 2017                     $30.00

[   ] June 28, 2017                        $30.00

[   ] October 18, 2017                 $30.00

[   ] All Three Courses                $75.00

Hygienist Name:___________________________________________________________________

How did you find out about this course? _______________________________________________

Doctor’s Office:____________________________________________________________________

Hygienist Address:__________________________________________________________________

Hygienist Address:__________________________________________________________________

Hygienist City, State, Zip:_____________________________________________________________

Hygienist Phone:____________________________________________________________________

Hygienist E-mail (REQUIRED):____________________________________________________________________

Method of Payment

Please Print this page and mail completed registration form with check made payable to : Periodontal Associates

LIMITED SEATING – SIGN UP NOW

Mail registration form and payment to:

Periodontal Associates, Inc.

29001 Cedar Rd. Suite 450

Lyndhurst, OH 44124

For more information please contact:

Phone: 440.461.3400

Fax: 440.461.1722

E-mail: [email protected]