Registration Form

Registration Form (Chicago, IL Course - Nov 7, 2010):

Practice Name:
Address 1:
Address 2:
City / State / Zip:
Practice Phone Number:
Attendee Name (First):
Attendee Name (Last):
Attendee E-Mail Address:
Attendee Phone Number:
Years in Clinical Practice:
Optometry School:
How did you hear about us:
Referred by:
Which of the following do you utilize in your practice?
- Contact Lens Technician
- Records Scribe
- Electronic Health Records
- Ocular Surgery Co-Management
Actively Treat Patients With:
- Glaucoma Patients / Week
- Dry Eye Patients / Week
- Ocular Allergy Patients / Week
Which of the Following Intrumentation is Available in Your Practice Location?
- Fundus Photography
- Threshold Visual Field Analyzer
- Anterior Segment Photography
- Retina/Optic Nerve Imaging
- Pachymeter
- Auto-Refractor
- Corneal Topographer
- Optomap
- Wave Front Analyzer
Average Patient Visits Per Week:

Payment Info:

If you have any registration related questions please contact cbrake@candeocsc.com