UC Davis Pediatric Heart Center Symposium

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REGISTRATION INFORMATION:
First Name
How would you like your FIRST name to display on badge (nickname)?
Last Name
Credentials
Affiliation
Who do you work for or represent?
E-Mail
Day Phone
Fax Number
Address
City / State / Zip / /
Do you need CME Credit?
Last Four of your SSN
If you need CME Credit, this is required.
REGISTRATION SPECIALTY:
Doctor
Resident
Fellow
Nurse Practitioner
Physician Assistant
Nurse
Sonographer
Respiratory Therapist
Medical Assistant
Patient / Family
Other

Are you a scheduled Speaker?
Are you UC DAVIS STAFF WORKING the event?
Executive Code: (Optional)

 

UCD PHC EDUCATION SYMPOSIUM v1.0