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You must have JavaScript enabled to use this form. Please complete the form below to register for the Rotator Cuff Rehabilitation to Replacement Conference. Contact Information Contact information First name Last name Phone (Please format your phone number with +1 at the start and dashes where required (-). Example: +1 519-646-6100): Type - Type -HomeOfficeCell Phone (Please format your phone number with +1 at the start and dash (-) where needed. Example: +1 519-646-6100): Ext: Email Organization: Mailing Address (for billing purpose): Role (please enter): Please include any dietary restrictions: Details: Vegan Gluten Free Other: Please list foods that trigger an allergic reaction or other dietary needs: Payer Information If payment will be provided under a different name than the name of the person registering, please enter the contact information for the individual completing payment below. This helps match up the registrant information if the credit card information is different. If payment will be provided under a different name, please enter the contact information for the individual completing payment: First name: Last name: Email: Registration Registration: Select registration type: $200 - Early bird registration, only available before April 1 $250 Regular rate (after April 1) $150 Student or St. Joseph's staff rate Payment Online payment by credit card - to complete your registration, please proceed with payment by credit card through Paypal by selecting the "Submit" button below. This personal information is being collected under the authority of the Public Hospitals Act R.S.O. 1990, CHAPTER P.40 for the purpose of contacting the sender in response to an inquiry. If you have questions about the collection of this information, please contact Privacy and Freedom of Information, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON,519-646-6100 ext. 65591. Thumbnail shoulder-surgery-hololens-view-during-surgery.jpg
