Register for Wasted Days

Please fill out our meeting registration form!

Salutation
First Name
Last Name
Name Suffix
Title
Organization
Mailing AddressHome   Work  
Address 1
Address 2
City
State/Province/Territory
State/Province/Territory (Outside North America)
Zip/Postal Code
Country
Phone (day)
Phone (cell)
Fax Number
E-mail address
Profession
State/Province/Territory Licensed in:
Attending Staff Members
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Name & Position
Total # of persons attending the retreat:
Names of attendees that will attend the billing bootcamp Saturday morning.
# of course attendees attending Friday night dinner:
# of additional guests attending Friday night dinner at $100 each:
Miscellaneous:
Date of Event You Are Registering For
In case of an emergency at the meeting, please contact this person:
Phone:
The organization reserves the right to substitute lecturers or to cancel or reschedule sessions due to low enrollment or other unforeseen circumstances.
What aspect of this meeting is of most interest to you?General Topic
Location
Lectures/Workshops
Networking
Acquiring CE Units
Other (Please explain)
Details:
Do you currently treat patients for sleep apnea?Yes   No  
On average, how many appliances do you seat per month?
Do you own/use any home sleep test units?Yes   No  
Are you currently using a dedicated EMR or software for your sleep practice?Yes   No  
Travel Plans
Arrival Date
Departure Date
Travel or other information you would like the event staff to know
Are there any special accommodations you need to make your conference experience more comfortable? (i.e., hearing assistance, accessibility, diet considerations)
Where did you learn about this course?
Details about your referral?
Elite Code, if any
# of dentists at $1895 each
# of team members at $695 each
Total Registration Cost
Will Attend Medical Insurance Boot Camp on Saturday Morning
Credit Card
Credit Card #
Expiration
Card Code
Cancellation Policy: Full refund less a $50 handling charge will be given if you cancel in writing 30 days prior to the opening of the meeting. No refund will be made for cancellations after this date.

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Newly Registered Speakers:

February 2011

Dustin Van Sloten

January 2011

Jennifer Bagley

January 09

 

 

 

 
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Meet Our Featured Speakers!

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Cell phones
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