2012 Joint OMA-South West LHIN Physician Sessions Survey

REGISTER BY WEDNESDAY NOVEMBER 7, 2012 FOR OWEN SOUND SESSION

Required fields are marked with an asterisk (*)

Please note: Your contact information will only be used to communicate with you regarding this event

If you have any questions regarding the sessions or online registration form, please contact Alexa Attard at 519-640-2596 or alexa.attard@lhins.on.ca

Saluation*:

Saluation*: Dr.

Ms.

Mrs.

Mr.

First Name:

Last Name:

City/Town:

Organization:

Department:

Medical Specialty:

Office phone:

Fax:

Email:

Will you be attending the complimentary dinner provided before the session?

Will you be attending the complimentary dinner provided before the session? Yes

If "yes", please indicate any special dietary needs

Please check box below

Please check box below Tuesday, November 13, 2012 - Stone Tree Golf and Fitness Club, Owen Sound

Please select the concurrent session that you would be interested in attending.

	1st Choice	2nd Choice
Integrated Primary Care Models - A Hub of Care	*Please select the concurrent session that you would be interested in attending. Integrated Primary Care Models - A Hub of Care 1st Choice	Integrated Primary Care Models - A Hub of Care 2nd Choice
Timely and Appropriate Referrals to Specialists	Timely and Appropriate Referrals to Specialists 1st Choice	Timely and Appropriate Referrals to Specialists 2nd Choice

Please note: If there is insufficient interest in any concurrent session, the session may be cancelled.

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2012 Joint OMA-South West LHIN Physician Sessions
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