Syphilis Training- Buffalo, NY 06/20/2013

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* 1. Will you be attending the Comprehensive Syphilis Overview in Buffalo?

Yes

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* 2. Name

Last, First *

Agency/Office: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 3. Degree(s)

CNM

Other

Other (please specify)

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* 4. Are you currently providing clinical care to patients?

Yes

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* 5. If your answer to Question number 4 is 'Yes', what is your practice setting?

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* 6. If your answer to Question number 4 is 'No', what is your role?

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* 7. Will you be requesting continuing education credits?

Yes

Not sure

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* 8. If you answered "Yes" to Question 7, which type of credits will you request?
(Please note: You must fill out an application on-site at the completion of the training to receive credits.)

CME

CNE

CHES

Question Title

* 1. Will you be attending the Comprehensive Syphilis Overview in Buffalo?

Question Title

* 2. Name

Question Title

* 3. Degree(s)

Question Title

* 4. Are you currently providing clinical care to patients?

Question Title

* 5. If your answer to Question number 4 is 'Yes', what is your practice setting?

Question Title

* 6. If your answer to Question number 4 is 'No', what is your role?

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* 7. Will you be requesting continuing education credits?

Question Title

* 8. If you answered "Yes" to Question 7, which type of credits will you request?(Please note: You must fill out an application on-site at the completion of the training to receive credits.)

* 8. If you answered "Yes" to Question 7, which type of credits will you request?
(Please note: You must fill out an application on-site at the completion of the training to receive credits.)