Event Registration

Sign up for:

[   ] June 15, 2022 ($40)

[   ] September 14, 2022 ($40)

[   ] December 14, 2022 ($40)

[   ] All Three Courses ($100)

Hygienist Name:_____________________________________________________________________________

Contact E-mail (REQUIRED):____________________________________________________________________

Address: ___________________________________________________________________________________

City, State, Zip Code: _________________________________________________________________________

Hygienist Phone: ____________________________________________________________________________

Doctor’s Office Name:_________________________________________________________________________

Method of Payment

Please Print this page and mail completed registration form with $40 per event or $100 for all three events.  Make your check made payable to : Periodontal Associates, Inc.

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]