2012 DRUG THERAPY DAY REGISTRATION FORM
Salutation:
Dr.
Mr.
Mrs.
Ms.
First name*:
Last name*:
Title:
Physician
Pharmacist
Other:
Department:
Organization:
Preffered Mailing Address:
Work
Home
Street:
City:
Province:
Postal Code:
Email*:
Phone*:
Fax:
REGISTRATION FEES:
$150
Advance registration
$50
Fellows/Students/Resdents (Proof required)
$175
Registration at the door
METHODS OF PAYMENT:
Cheque
Cheque must be mailed to our office. See payment submission information below.
Visa
Credit card information must be faxed to our office. See payment submission information below.
Mastercard
Payment Submission Information:
Registration forms with credit card information may be faxed to (519) 663-3232.
Please make cheques payable to
Lawson Health Research Institute - "Drug Therapy Day"
, and send this registration form to:
Drug Therapy Day
c/o Andrea Fragassi, Event Coordinator
LHSC-University Hospital (LHSC)
339 Windermere Road, Room C5-137
London, Ontario N6A 5A5
Enquiries:
Andrea Fragassi - Tel: (519) 685-8500 ext. 35180, Fax: (519) 663-3232