MPRC

• First Name
• Last Name
• Email Address
• Phone (###-###-####)
• Institution Name
• Street
• City
• State
• Zip
• Name as you would like it to appear on your name badge
• JUDGE/MODERATOR ASSIGNMENTS (please select multiple) Primary Care/Ambulatory Care Clinical Services Management Internal Medicine Infectious Disease Pediatrics/Neonatology Hematology/Oncology Critical Care Cardiology Community Practice Pharmacy Practice Transplant Psych
• Overnight Accommodations (please select one) I will be commuting I am making reservations at the Embassy Suites I am making reservations at another hotel I will be sharing a room with another preceptor I will be sharing a room with a resident I am staying with friends or family
• Roommate's Name(s) - Preceptor or Resident
• Payment Options Select One
  Pay online with credit card
  Mail a check
  

REGISTRATION FEES

You must select at least one item!

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