2019 Event Registration

[ ] April 3rd, 2019 $30.00

[ ] June 19th, 2019 $30.00

[ ] September 25, 2019 $30.00 (NOTE THE DATE HAS CHANGED FROM SEPTEMBER 18TH)

[ ] All Three Courses $75.00

Hygienist Name:___________________________________________________________________

How did you find out about this course? _______________________________________________

Doctor’s Office:____________________________________________________________________

Hygienist Address:__________________________________________________________________

Hygienist City, State, Zip:_____________________________________________________________

Hygienist Phone:____________________________________________________________________

Hygienist E-mail (REQUIRED):____________________________________________________________________

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