Class Registration

Email(Required)

Phone(Required)

How Long Have You Been Practicing?

What State Are You Licensed to Practice in?

Do You Own Your Own Practice?

Your Credentials

(e.g. NP, RN, MD)

Medical Conditions(Required)

Please list any medical conditions or allergies we should know about

Payment Terms(Required)

You can either pay a 25% deposit or the full amount.

November Classes (25% Deposit)

November Classes (Full Amount)

December Classes (25% Deposit)

December Classes (Full Amount)

Processing Fee (3%)

Price: $0.00

Total

Credit Card