Micromedical Technologies, Course Registration


	Balance Centers

	VNG / ENG
	VisualEyes
	VORTEQ/DVA

	Balance Platforms
	Balance Quest

	Rotational Chair
	System 2000

	Video Goggles
	RealEyes xDVR
	RealEyes
	InView

	Caloric Irrigators
	Air Fx

Advanced Vestibular Testing - State of the Art 2010

Note: Fields in RED must be entered to submit information. A representative of Micromedical Technologies will contact you within 2 business days to confirm and receive payment information. You can also print a copy prior to submission for your records. Alternatively you can print this form and mail your check payable to Micromedical Technologies to our corporate office:

ATTN Course Registration
Micromedical Technologies
10 Kemp Drive
Chatham, IL 62629

Personal Identification

Name (First & Last):	Note: Accented and Tilde characters should be substituted with English characters (e.g. replace é with e)
Specialty:
Company Name:	If not affliated with a particular company, please specify none.

Address Location	Business Address Home Address
Address:

City:		State:
Zip:		Country:
Daytime Phone: M-F 8am - 5pm CST		Fax:

Email:


Registration Type
	Friday & Saturday Course ($500 on or before 5/4/2010, $550 after 5/4/10)

Payment Method
	Visa or Mastercard	Check

Course Information
Location: St. Louis, MO Dates: Friday, June 4 and Saturday, June 5, 2010 Instructors: Joel A. Goebel, M.D., F.A.C.S.; Tucker Gleason, Ph.D.; Belinda Sinks, M.A., CCC-A; James Soileau, M.D.; Richard Miles, Ph.D.

Additional Information Question/Comment (Limit 8 lines): Note: DO NOT ADD YOUR CREDIT CARD INFORMATION. A Micromedical Representative will contact you by phone for that information.