Event Registration

November 10th, 2021

FEE: $40.00 for 2.5 CE units for 2021 Continuing Education requirement

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 $40 check made payable to : Periodontal Associates

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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