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Registration Form:

To register, please complete the form below and submit. A CEDH representative will contact you to arrange payment. You may also download our brochure, print and complete the registration page and mail or fax to CEDH.


First Name Last Name
Credentials License Number
Specialty Title
Office/Institution
Business Address
City State Zip
Office Phone Office Fax
E-mail

Hospital
Other Affiliation
Registration Fees
$2,000 - 136 hours of training and all course materials

$1,400 - 136 hours of training and all course materials (if registered by October 15, 2007)

$500 - Current medical students, 136 hours of training and all course materials (please supply copy of student ID)
Location
Payment - we accept checks, Visa, MasterCard and American Express. A CEDH representative will contact you to arrange payment.