Request a Meeting Form
To request a meeting for your institution, complete the following Request a Meeting application. For questions, please contact Asma Akram, Senior Projects Coordinator, at AAkram@i3Health.com or 973-928-8085 ext 225.
Name
*
First Name
Last Name
Email
*
example@example.com
Title
*
Phone Number
*
Please enter a valid phone number.
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Please tell us about your organization.
Organization Name
*
Organization Type
*
Academic institution oncology treatment center
Community-based center affiliated (satellite) with a larger academic treatment center
Community-based center affiliated (satellite) with a larger treatment center (not academic)
Community-based treatment center (stand-alone, no affiliation)
Veterans Health Administration hospital
Cancer registry
Private oncology practice
Community Clinical Oncology Program member institution
Association of Community Cancer Centers member institution
Inpatient treatment center
Outpatient treatment center
Hematology/oncology fellowship program
Oncology Nursing Society chapter
Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Educational Needs
Please rank the educational gap at your institution related to Rett syndrome.
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
How many physicians are expected to attend this activity?
*
How many nurses are expected to attend this activity?
*
How many pharmacists are expected to attend this activity?
*
How many other health care professionals are expected to attend this activity?
*
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Meeting Details
Please let us know your preferred meeting dates and times by selecting a date within the range of 9/1/23 - 7/15/24 from the calendars below.
Date
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Where will the meeting take place?
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please verify that you are human
*
Submit
Should be Empty: