Physician Meeting Registration

Congratulations on your decision to attend a private presentation of “Love Practicing Medicine Again!”

Please complete the information below to register.

  = Required Information

	Meeting Registration Code
	Last Name:
	First Name:	MI:
	Primary Specialty:	Cardiovascular Disease Endocrinology Family Practice General Practice Geriatrics Internal Medicine Nephrology Obstetrics/Gynecology Pediatrics Pulmonary Diseases Rheumatology Other     %:
	Secondary Specialty:	Cardiovascular Disease Endocrinology Family Practice General Practice Geriatrics Internal Medicine Nephrology Obstetrics/Gynecology Pediatrics Pulmonary Diseases Rheumatology Other     %:
	Practice Name:
	Total Years in Practice:
	Total Years Practicing in This Community:
	Are you Accepting New Patients:	Yes    No
	Are You Board Certified:	Yes    No
	Number of Doctors in Group:	Solo   2-3    4-6    >6
	Practice Environment:	Community   Hospital   Nursing Home Other
	Are You Emplolyed by:	Self    Hospital    Group    Other
	Patient Insurance (%):	Medicare  PPO  POS        HMO             HMO Medicare        Cash
	Total Hours Per Week Seeing Patients in the Office:
	Number of Active Patients:	<1000   1000-2000   2001-3000   >3000
	Average Number of Patients Seen Per Day:	<10   11-15   16-22   >23
	Where Did You Complete Your Residency:
	Year of Residency Completion:
	Hospital Affiliation(s):
	Spouse attending meeting:	Yes    NoSpouse's Name:
	Business Phone:	( )- -
	Fax:	( )- -
	Email:
	Cell:	( )- -
	Backline:	( )- -
	Get the Newsletter
	MDVIP HIPAA	I have read and agree to MDVIP HIPAA
	MDVIP Confidentiality	I have read and agree to MDVIP Confidentialty

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