Registration Form
Documentation for Reimbursement
Challenge (Urology)
Registration/Payment Details
My Registration
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Documentation for Reimbursement Challenge (Urology)
$
1,097.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Practice Name
*
Registrant's Name
*
First Name
Last Name
Registrant's Email
*
Confirmation Email
example@example.com
Registrant's Mailing Address (for Pocket Card and Wall Chart)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registrant's Role
*
Please Select
Urologist
APP
Submit Registration and Payment
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