* 1. First Name

* 2. Last Name

* 3. Degree(s)

* 4. Institution/Practice

* 5. Please select one

* 6. License Number(s) - Please type NA if you do not have a license number

* 7. State(s) of License - Please type NA if you are not licensed in the US

* 8. NPI Number (US registrants only)

* 9. Country

* 10. Preferred E-mail

This event complies with PhRMA guidelines. Attendance is limited to eye care professionals. Accordingly, we appreciate your support in not bringing a spouse or guest to this program. Healthcare professionals licensed in Minnesota and Vermont may not attend this event due to their respective state laws and regulations that restrict the provision of meals to healthcare professionals.
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