Health & Continence Institute

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                                                         Social security #  (for CEU's)

_____________________________________________________

Name of Medical Practice

________________________________________________________________________

Office Address                                       City                                                  State

____________________________

Telephone

Cost $10,000 per pracitce.  1/2 off for second person from same pracitce 

Now accepting PAYPAL or make check payable to HCI- Helen Carcio and mail with this registration form  to:          Helen Carcio

                                              Box 411

                                              Charlemont, MA 01339

Full faculty disclosure will be provided at the program.