COPD Summit Registration Form

1. COPD Summit Registration Form

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* 1. Select the Summit that you are registering for.

Massachusetts COPD Summit

Southeast Regional COPD Summit

For more information on the Southeast Regional COPD Summit Visit:
http://www.copdfoundation.org/NewsEventsNEW/UpcomingEvents/tabid/172/vw/3/ItemID/15/d/20101115/language/en-US/Default.aspx

For more information on the MA COPD Summit visit:
http://www.copdfoundation.org/NewsEventsNEW/UpcomingEvents/tabid/172/vw/3/ItemID/12/d/20101109/language/en-US/Default.aspx

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* 2. Name

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* 3. Credentials

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* 4. Organization

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* 5. Title

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* 6. Address

City/Town:

State:

ZIP:

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* 7. Telephone #

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* 8. Email Address

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* 9. I am a

Patient

Physician / General

Physician / Pulmonologist

Nurse / Nurse Practitioner

Physician Assistant

Respiratory Therapist

Pharmacist

Public Health Professional

Payer of Healthcare Services

Pharmaceutical Company Employee

Other (please specify)

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* 10. I heard about the Summit through

The COPD Foundation

Referral from a colleague

Other (please specify)

The Southeast Summit is sponsored by Boehringer Ingelheim Pharmaceuticals, Inc.

The Massachusetts COPD Summit is sponsored by Boehringer Ingelheim Pharmaceuticals, Inc.

Meal expenses are sponsored by the COPD Foundation.

For more information please contact Jamie Lamson at
1-866-731-COPD (2673) Ext.455, jlamson@copdfoundation.org