Please fill out the form below in order to register
First Name*
Last Name*
Address*
Apt #*
City*
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AK
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AR
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Zip Code*
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Home:
Office:
Cell:
Email Address*
May we send you a post event e-mail questionnaire?
Yes
No
Do we have your authorization to provide your e-mail address to participating specialists & physicians?
Yes
No
Admission is $35.00
Number of Tickets
x $35.00 each =
Do you prefer a vegetarian meal?
Yes
No
Seminar Schedule Preferences - Please select the seminars you would like to attend (only 1 per time slot).
9 a.m.
Cardiac Disease / Matt Glover, MD
Colon Cancer / David Shibata,MD
Cervical, Ovarian & Uterine Cancer / Giselle Ghurani, MD
None
10:30 a.m.
Migraines & Other Headaches / Susan Steen, MD
Skin Cancer / RobertTawil, MD
Menopause / Madelyn Butler, MD
None
1:30 p.m.
Osteoporosis / Joel Silverfield, MD
Sleep Disorders / Stephen Kreitzer, MD
Breast Cancer / Brad Carter, MD
None
3 p.m.
Fertility / Barry Verkauf, MD
Dry Eye / Steven Maskin, MD
Nutrients & Cancer Prevention / Nagi Kumar, PhD, RD
None
Do you work part-time or full-time?
Full Time
Part Time
Sex
Male
Female
Household Income
$25K
$26-$50K
$51-$75K
$76-$100K
$101K+
Age
25 and under
26-35
36-45
46-55
56-65
66+
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