HC INSTITUTE for Health Professionals
Certificate Program in “How to Establish and Manage a Center for Bladder Health”
Please register for this exciting opportunity by completing and returning this form
Please complete for each individual attending.
Registration Form
Name __________________________________________________________________
(last) (first) (middle) (degree)
________________________________________________________________________
Home Address City State
__________________________
Email
_____________________________________________________
Name of Medical Practice
________________________________________________________________________
Office Address City State
____________________________
Telephone
- Educational seminar $1850 per person
- Discount for individuals from same practice as approved by HCI for $500 off the conference fee
Please make check payable to HCI- Helen Carcio and mail with this registration form with $100 deposit to: Helen Carcio
Box 411
Charlemont, MA 01339
Full faculty disclosure will be provided at the program.
