Application for Continuing Medical Education Program

 

Name_______________________________________________

Address_____________________________________________

City________  State_____  Country _______  Zip Code______

Phone Number_______________    Cell___________________

Email_______________________________________________

 

The required fee for each 1.5 day program is $1200.00

(non-refundable) and must accompany the application.

Please make checks payable to:

International Research Foundation for RSD/CRPS

1910 E. Busch Boulevard

Tampa, FL  33612

Phone: 813 907-2312

 

 

    Anthony Kirkpatrick, MD, PhD

Tampa, Florida USA

                                           

 

 

Signature_________________________________    Date _______________