NISE-Stim® Course Host Request

NISE-Stim® Course Host Request

Thank you for being interested in hosting a NISE-Stim® course. We'd love to learn more about your clinic - please complete the form below. We will be in touch soon. Thank you!
Host Clinic Information:
Clinic Name
Clinic Contact Name

First NameLast Name
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number with Country Code

CountryArea CodePhone Number
E-mail
example@example.com
Instagram or Facebook so we can Share the Advertising
Have you ever hosted a course before?
What course(s) are you interested in hosting?
Do you have a preference on course instructor?
What language would you like the course taught in?
If you selected "other" above, what language would the course need to be interpreted into and will you have an interpreter?
How many co-workers do you have that are interested in taking the NISE-Stim® course?
How many co-workers do you have that are interested in taking both the NISE-Stim® Level 1 and 2 courses?
Are you able to advertise the course?
Do you have a list of therapists to whom you would disseminate the information?
How many attendees can the space accommodate for the course? We need at least space for 12 in USA, 15 internationally
Will you be able to find the children for demonstration treatments, we need at least 6 different children per course.
If outside of the USA, can e-stim units with symmetrical bi-phasic current appropriate for pediatric use be found in your country? You may need to search the internet. Please add the name of the unit and approximate cost. We can bring units for teaching, but being able to find e- stim units in your country will make it much easier for your clinic and patients.
What month(s) are you able to host?
Do you have a specific start date in mind?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Anything else you'd like us to know?
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