Registration Form
Documentation for Reimbursement
Challenge (For Urologists)
Registration/Payment Details
My Registration
*
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Documentation for Reimbursement Challenge (Urology)
For Urologists
$
1,097.00
Additional Registrants
For Urologists
$
1,097.00
Quantity
1
2
3
4
5
6
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Email Address to Send Payment Receipt To
*
example@example.com
Contact Information
Contact Name (if different form Registrant 1 below)
Practice Name
*
Practice Address (where to ship Pocket Card & Wall Chart)
*
Registrant Information
Registrant 1
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Registrant 2
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Registrant 3
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Registrant 4
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Registrant 5
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Registrant 6
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Registrant 7
Registrant's Name
*
Registrant's Email
*
Registrant's Mailing Address (for Pocket Card & Wall Chart) [IF DIFFERENT FROM PRACTICE ADDRESS]
Submit Registration and Payment
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