Perio Institute, Inc. | Course Registration

Perio Course Registration Form

* First Name

* Last Name

* Address 1

Address 2

* City

State / Province

* ZIP

Fax

* Phone

* Email

Check this box if you would like to receive emails regarding classes in your area.

* AGD Member (Select Yes or No)

Yes No

AGD Member Number

Course Information

Course Name

Course Date/Location

Payment by Credit Card

Perio Institute will charge your credit card a $50.00 deposit to hold your registration when you register for a course. Perio Institute will charge the balance of the registration fee to your credit card when we send the 2nd confirmation, usually 4-5 weeks prior to the course date. Your deposit will be refunded if the Perio Institute cancels the course for any reason or if you cancel at least two weeks prior to the course date. If you cancel within two weeks of the course date, Perio Institute will refund 70% of the registration fee and credit 30% toward a future course of your choice.

Perio Institute will NOT be responsible for any costs incurred or potential earnings lost due to course cancellations.

I have read and agree to the above policy regarding my deposit and course registration fee.

Payment by Check

To pay by check, please send full payment along with your registration information (you can print this page) to the address below. Your payment must be received at least two weeks prior to course date. Unless the course is cancelled, Perio Institute will cash your check two weeks prior to the course date.

Perio Institute

Attn: Course Registration

7829 Center Blvd SE #300

Snoqualmie, WA 98065

Available Courses:

Next Step Bone Grafting

Enhancing Restorative Results

Implant Continuum

Crown Lengthening

Soft Tissue Grafting

Bone Grafting & Gtr Level 1

Bone Grafting & Gtr Level 2

Periodontal Surgical Skills Workshop

Oral Surgery for the GP