Thursday, November 9, 2017
Event is from 9AM – 4PM
UC Irvine Medical Center,
Building 53, #113/114/115
101 The City Drive South, Orange, CA 92868
Fields marked with an asterisk(*) are required.
Registration fees*:


*Limited On-Site Registration Available: $150.00
Personal information
First name*:
Last name*:
Credential:
Clinical license number:

Home address
Street 1*:
Street 2:
City*:
State*:
Zip*:

Practice information
Practice name/affiliation*:
Street 1*:
Street 2:
City*:
State*:
Zip*:
Email address*:
Daytime phone*:
Fax:
For questions or more information, please contact Stefanie Yoshii at
email syoshi@uci.edu.

Cancellation policy: For cancellations made by November 3rd, 2017.
Send cancellation requests through email to syoshi@uci.edu.