Experts in Arthritis Registration Form - New Orleans, LA

1. Experts in Arthritis Seminar

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100% of survey complete.

Please join us for an afternoon with world-class experts in arthritis care who will inform you about current scientific evidence and management strategies in the treatment and care of osteoarthritis, rheumatoid arthritis, and juvenile arthritis.

Date:______May 22, 2012_____

Time:________2:00 to 5:00 PM__

Location:__Tulan Medical Center,New Orleans, LA

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* 1. Please Register Below:

Name: *

Company/Organization (if applicable):

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country:

Email Address:

Phone Number: *

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* 2. What is your relationship to the disease?

Person with Arthritis

Caregiver

Family Member

Professional

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* 3. What is your area of interest?

Osteoarthritis

Rheumatoid Arthritis

Juvenile Arthritis

Other (please specify)

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* 4. Please list a question(s) you would like the experts to answer.

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* 5. How did you hear about the seminar?

American College of Rheumatology (ACR)

Arthritis Foundation

Centers for Disease Control and Prevention (CDC)

Friend/Colleague

Occupational Therapist

Physical Therapist

Public Library

Radio

Registered Day of Event

Rheumatologist

Senior Center

U.S. Bone and Joint Initiative Website

Other (please specify)

PHOTO RELEASE
I hereby grant the U.S. Bone and Joint Decade/Initiative and its affiliates specific permission to reproduce, publish, circulate copyright or otherwise use any and all photographs and/or electronic reproductions (slides, video) of myself taken at the Experts in Arthritis Seminar.

Signature:______________________________________________

Print Name:_____________________________________________

Date:__________________________________________________

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* 6. Would you be interested in obtaining updated information regarding arthritis and related diseases?

Yes

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* 7. For Office Use Only: Attended Session

	Yes	No
Attended	Attended Yes	Attended No