2026 NeuroVisual Medicine Annual Summit Registration

Attendee Name

PrefixFirst NameLast Name

Attendee Title

Owner, Doctor, Admin, NeuroVisual Coordinator etc.,

What best describes your role in the practice?

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Practice Name

Are you planning to bring a Significant Other (Partner)?

Guest Name

First NameLast Name

Are you planning on bringing any staff members?

How many staff members would you like to register?

Staff #1 Name

First NameLast Name

Staff #1 Title

Manager, NeuroVisual Coordinator etc., Scribe, Tech, etc..

Staff #2 Name

First NameLast Name

Staff #2 Title

Manager, NeuroVisual Coordinator etc., Scribe, Tech, etc..

If registering three or more non-OD staff members, please list each additional staff member’s name and title below.

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Total Number of People Attending from your Practice

Do you or anyone attending have any dietary restrictions or food allergies that we should know of?

Registration

OD / Owner (Conference Full-Access)

The Guest would include spouse, partner or significant other non-OD and not an employee.

$525.00 Quantity

Non-OD NVM member (Conference Full-Access)

Office Manager, or NeuroVisual Coordinator or other non-OD employee

$425.00 Quantity

Total

You will be invoiced for the full registration amount once all attending parties from your organization have completed the registration process. Please have each attendee register separately to allow for an accurate head count.

Questions, comments, concerns? Call us +1 220-204-2011 or Email Issy@neurovisualmedicine.com