Pristine Hygiene Club Registration Form

After we receive your registration form you will receive a confirmation email from Jenna our Marketing Director indicating
you’re an exclusive Pristine Hygiene Club Member.

Name*
Personal Email Address **
Birthday
MM slash DD slash YYYY
Home Address
Street Address Address Line 2 City State ZIP Code
Practice Name(s)
Practice Phone Number*
Practice Address
Street Address Address Line 2 City State ZIP Code
Topics and speakers you’d like the Pristine Hygiene Club to offer?
For future scheduling purposes which night of the week are you typically available to meet and what time?
RSVP: At this time we’re trying to gather a rough estimate of Pristine Hygiene Club members attending each course. If you’re unsure at this time if you’re able to attend please indicate that below. Regardless, each member will receive an email in December and May to confirm attendance. If you’re unable to attend either course but would like to participate in the Pristine Hygiene Club next year please feel free to complete the registration form and let us know in the comment section below. If we have availability you will have an opportunity to join again next year. The goal for our second academic year is to offer additional programs to our exclusive Pristine Hygiene Club Members.
Will you be attending Beyond the Pinhole: Changing Gingival Phenotypes Using Acellular Dermal Matrix with Dr. Abbey Sayed on Tuesday, January 29th, 2019, 6:30 - 9:00 pm?
- Yes
- Unsure
- No
Will you be attending Interdisciplinary Treatment Planning Workshop with Dr. Abbey Sayed on Thursday, June 6th, 2019, 6:30 - 9:00 pm?
- Yes
- Unsure
- No
Comments
* Correspondence and notification of meetings are sent via email.
Name
This field is for validation purposes and should be left unchanged.

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