registration form - laborie750.00 $750.00 fecal incontinence diagnostics course select program...
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$750.00
$750.00
FECAL INCONTINENCE DIAGNOSTICS COURSE
SELECT PROGRAM
Please fax your registration form to Course Coordinator at 1-802-878-1122 or email to the following address: [email protected] Registration also available at www.laborie.com/education.Confirmation letter will be sent upon receipt of payment.
Cancellation Policy
*Total (US Dollars)
REGISTRATION FORM2016 COURSES
DATE AND LOCATION QUANTITY UNIT PRICE (USD) AMOUNT
March 11 – Las Vegas, NV Massarat Zutshi, MD & Thomas Schroeder, MD
September 24 – Cleveland, OH Massarat Zutshi, MD & Thomas Schroeder, MD
Item No. COU003
LABORIE, 400 AVENUE D, SUITE 10, WILLISTON, VERMONT, 05495-7828, USA TEL: 800.522.6743 FAX: 802.878.1122
Innovation for Pelvic Health
Cancellations made 11 days+ before first course day — LABORIE will apply course fee to a future course or refund tuition minus a $150.00 administrative fee. Cancellations made 10 days or less before first course day, or no shows, will not be refunded. LABORIE reserves the right to cancel any or all parts of these workshops without prior notice and shall not be held responsible for any costs incurred by registrant.
CHECK (Payable to LABORIE) 400 Avenue D, Suite 10, Williston, Vermont 05495-7828 USA
OTHER
CREDIT CARD
Credit Card
Card Number
Credentials
Credentials
Credentials
Credentials
1.
2.
3.
4.Expiration Date (MM/YY)
Cardholder Name
Signature of Cardholder
PAYMENT PARTICIPANTS (Print name as you wish it to appear on certificate)
CONTACT INFORMATION Date
Name
Clinic / Practice
Address
City
Zip/Postal Country
Telephone
Fax
Email 1
Email 2State
LABORIE Cust. #(if known)
*Price does not include applicable state taxes unless specifically stated E.&O.E
Receipt RequestedProvide Email here(if different from above)