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Billing for Sleep Registration Form

Please fill out our event registration form!

First Name
Salutation
Last Name
Name Suffix
Title
Organization
Mailing AddressHome   Work  
Address 1
Address 2
City
State/Province/Territory
State/Province/Territory (Outside North America)
Zip/Postal Code
Country
Phone (day)
Phone (evening)
Fax Number
E-mail address
Profession
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Billing Seminar $495 each attendee
Total Number of Attendees for Billing Seminar
Names of Attendees for Billing Seminar
In Office Observation $300 (doctor)
Total Number of Doctors Observing
Names of Doctors Observing
In Office Observation $100 (Team Member)
Total Number of Team Members Observing
Names of Team Members Observing
Dinner and Roundtable Discussion on How to Build Your Sleep Practice $200 per person
Total Number Attending Dinner
Names of Doctors and Team Members Attending Dinner
In case of an emergency at the meeting, please contact this person:
Phone:
The organization reserves the right to substitute lecturers or to cancel or reschedule sessions due to low enrollment or other unforeseen circumstances.
What aspect of this meeting is of most interest to you?General Topic
Location
Lectures/Workshops
Networking
Acquiring CE Units
Speakers (Please tell us who)
Other (Please explain)
Details:
Travel Plans (If known at this time)
Arrival Date
Departure Date
Are there any special accommodations you need to make your conference experience more comfortable? (i.e., hearing assistance, accessibility, diet considerations)
Where did you learn about this course?
Total Registration Cost
Credit Card
Credit Card #
Expiration Date
Card Code
Cancellation Policy: Full refund less a $50 handling charge will be given if you cancel in writing 30 days prior to the opening of the meeting. No refund will be made for cancellations after this date.

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Our Newest  Event:

Wasted Days and Sleepless Nights

 Newly Registered Speakers:

Rubin Cheek

Fred Weiner

J.A. Shapira

 

 
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"The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn."
   -- Alvin Toffler

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THIS MONTH'S  POLL

Phones and Pagers at Meetings

When asked to turn off your phones and pagers at a meeting, what action do you take?
I turn it off
I put it on vibrate
I leave it on ring
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