Physician Program Registration Form

Mail-In Registration Form

Print out a copy of this form. Fill in the needed information and indicate the program(s) and date(s) you wish to attend. Please print clearly! Mail the form with a check in the correct amount payable to: Med•Lantic Management Services, Inc.
Note: Credit card payments are not accepted for mail-in registrations. Use our online registration if you wish to pay by credit card.

Cost for First Program Selected - $50 per person

Cost for Each Additional Program - $25 per person

Program	Specify Code	Specify Date	Cost
Disclosing Unanticipated Medical Outcomes to Patients
Medication Errors
Specialty Specifics
Case in Point
Total Cost

Name:
Address:
City:	State:	Zip:
Office Phone #:
Office Fax #:
License:
Specialty:
Notes:

Enclose the completed form and a check with full payment in an envelope and mail to:

Med•Lantic Management Services, Inc.
P.O. Box 64100
Baltimore, MD 21298-9134