Register for Collaborate 09
Please make sure that you have filled in all the required fields.
Salutation
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Dr.
Mr.
Ms.
Mrs.
Prof.
*
Your Role
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MD
Nurse
NP
Clinic Manager
IT Support
MOA
Other
*
First Name:
*
Last Name:
*
Clinic Name:
*
City
:
*
Province
:
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AB
BC
MB
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NL
NS
NT
NU
ON
PE
QC
SK
YT
other
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Phone
(only numbers):
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Email
:
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How many others from your clinic will be attending?
List the names of others attending from your clinic:
Preferred method of payment:
Cheque
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Special Requests – dietary, access, etc.:
Billing Adress:
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Tel: 604.576.6969 | Toll Free 1.866.879.9653 |
collaborate09@wolfmedical.com
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