Follow the four simple steps below to register online. * indicates required fields.

Please keep this form as confirmation of your registration - no other confirmation will be generated or sent.

Date & Location

Please select the event you would like to attend:*

--None-- September 16, 2008, Naples, FL September 17, 2008, Ft. Lauderdale, FL September 25, 2008, Kansas City, MO October 1, 2008, New Britain, Connecticut

Describe Your Practice

Number of Physicians:*

Timeframe to select an EHR system:* --None-- 1 to 6 months 6 to 12 months Just beginning to research None of the Above

Include Your Contact Information

Name of Practice:*

Address: *

City:*

State:*

Zip:*

PRIMARY CONTACT

First Name:*

Last Name:*

Title:*

Contact Phone:*

Fax:

Contact Email:*

List Who Will Be Attending

Attendees:*

(Please enter name, title, name, title, etc.)