UNITE 360 Surgical Skills Course Registration

UNITE 360 Surgical Skills Course Registration - San Diego

Pendry San Diego

550 J St, San Diego, CA 92101

Friday, April 26th

7:00PM: Welcome Reception/Dinner

Saturday, April 27th

7:30AM - 8:30AM: Breakfast

8:30AM - 2:30PM: Lab

3:00PM - 4:00PM: Case Review/Discussion

4:00PM - 4:15PM: Closing

We recommend you bring your own pair of scrubs, but we will have scrubs to borrow if needed. Scrubs will be available on Saturday morning during breakfast.

First Name*

Last Name*

Phone Number*

Phone

Email Address*

Home Address*

Please enter your full address, including city, state and zip.

Are you driving or flying to this event?*

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Select your gender*

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Date of Birth*

Enter your name as it appears on ID*

Enter your home airport*

Enter TSA Precheck # if applicable

Enter seat preference *

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Do you need a hotel room? *

*Medline compliance allows for a 1 night hotel stay for April 26-April 27th only. Pending departure flight times on April 27th, requests to extend your stay until Sunday, April 28th may be covered by Medline.*

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Please select your applicable role*

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What best describes your role?*

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Enter your NPI number*

Enter your Residency Training Program Name*

Enter your Residency Training Program Location*

Enter your Residency Training Completion Date*

Enter your Fellowship Training program name*

Enter your Fellowship Training program location*

Enter your Fellowship Training Completion Date*

Enter your Employer/practice name*

Enter your employment location*

Enter your faculty surgical privileges *

Enter your distributor name*

Are you attending the Welcome Reception/Dinner*

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Please list any dietary restrictions*

Scrub Top Size

Scrub Bottom Size

Are you familiar with Medline UNITE?*

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What UNITE products are you currently using?*

Who is your current Medline UNITE distributor/rep?*

How did you hear about this program?*

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