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Hygiene Study Club Online Registration Form

Name *
Name
Mobile Phone
Mobile Phone
Address
Address
Section
My current Oregon RDH License Expires on this date: *
My current Oregon RDH License Expires on this date:
I understand it is my responsibility to verify that my Oregon RDH license is up-to-date in order to participate in the Hands-On Learning Clinic Feb 2018. *
I understand it is my responsibility to make sure my Membership Payment is sent and received at the Beaverton Periodontics office and that once it is received and processed, payments are nonrefundable. *