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Registration Form
Psychiatry & Behavioral Health Conference
Please complete this form to register for the conference. Advanced registration and payment is required.
Click here
to view payment options.
*
Name (First and Last):
(Required.)
Degree (i.e. MD, PA, NP):
Organization Name:
*
Mailing Address:
(Required.)
*
City, State & ZIP:
(Required.)
*
Phone (Daytime):
(Required.)
*
Email Address:
(Required.)
*
I will attend the conference:
(Required.)
In person
Virtually
If you are attending in person and have any dietary restrictions, please list them below:
*
Registration Fee:
(Required.)
Physicians - $100
Allied Health & Other Professionals - $50
Medical Residents/Students - $10
*
I will pay the registration fee by:
(Required.)
Check
(make payable to Marshfield Clinic and mail to Marshfield Clinic; Conference Registration-GR (Lawton Building); 1000
N Oak Ave; Marshfield WI 54449)
Credit Card, call 715-389-3776 to make payment
(Marshfield Clinic accepts MasterCard, VISA,
American Express, Discover)
Thank you for your registration. If you have any comments, please list them below. Click the
Submit Registration
when finished.
