First Name: *
Last Name: *
Medical Center/Hospital/Organization: *
Are you employed by a hospital-based or a private practice?:*(Please select one)
Hospital-Based Practice Private Practice Other
title *
Designations: * (Select up to two degrees)
Preferred Mailing Address 1: *
Preferred Mailing Address 2:
City: *
State: *
Zip: *
Primary Email: *(Format: email@domain.com)
Telephone (Day): *(Format: XXX-XXX-XXXX)
Mobile Phone: *(Format: XXX-XXX-XXXX)
Country: *
Confirm Primary Email: *(Format: email@domain.com)
Secondary Email: (Format: email@domain.com)
Confirm Secondary Email: (Format: email@domain.com)
Select a Profession:*(Please select one)
US STATE OF PROFESSIONAL LICENSURE: *
US STATE OF PROFESSIONAL LICENSURE 2:
License #: What is this
SPECIAL SERVICES (ADA):What is this
* All Physicians in training must submit a letter to MLescanoFeher@ccmcme.com from their program director on institutional letterhead confirming their medical student / fellow / resident status in order to obtain the complimentary registration code.
WHAT CONTRIBUTED MOST TO YOUR decision TO REGISTER? *
HAVE YOU ATTENDED VENOUS SYMPOSIUM VIRTUAL IN THE PAST?
May we use your email address for symposia-related communications and communications from symposia affiliates?
For more information about how Complete Conference Management uses your email and other personal data, please review the Complete Conference Management Privacy Policy. I acknowledge that I have reviewed the Privacy Policy.
Years of Practice*
You will receive your personal join link via email on the week of the symposium. Be sure to check your spam/junk folder.
