Honoring Dr. Rodger Lofland
1902 N. Sandhills Blvd.
Aberdeen, NC 28315
(800) 682-4191
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Study Club Enrollment

Enrollment is easy! Use either of the following methods:

  1. Complete the form below indicating your payment information, then print and fax the form to 910.692.3919.
    PLEASE NOTE: No information will be transmitted over the Internet.

  2. Complete the form below indicating your payment information. Print it and mail the form. If you prefer to pay by check, please include your check.

Direct your questions or concerns to Renate at 800.682.4191.

Doctor's Name:
Practice Name:
Address:  
City:  State: Zip:
  General Practice Oral Surgeon Periodontist Other
Office Phone: Email Address:
Additonal Members: Doctor Auxilary
  Doctor Auxilary
  Doctor Auxilary
  Additional Members Fees: Doctors - $500, Auxilary - $125
  Sessions you plan to attend:   Thursday Friday Saturday
  Golf on Saturday afternoon?   Yes No
    Total # of golfers:     ($75.00 per golfer)
Payment Method:   Total Due:      
Credit Card:  
  Card #:          
Exp. Date:       
  Name on Card:
Security Code: 
E-Check: Name of Bank:
  Routing #:       
  Account #:    
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