2020 Event Registration
Sign up for:
[ ] June 10th, 2020 $30.00
[ ] September 16th, 2020 $30.00
[ ] December 2nd, 2020 $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]