Seminar Online Registration Form

Seminar Registration  Signup Form

Seminar Name(required)

Seminar City (required)

Seminar Date (required)

Attendees Name DC (required)

Ohio DC Lic#(required)

Acupuncture Lic#

Your Office Name (required)

Your Address (required)

Your City (required)

Your State (required)

Your Zip Code (required)

Work Phone (required)

Cell Phone

Fax

Your Email** (required)

Please verify all entries before submitting form.

**(Your email address will be used to electronically send your seminar course notes, 3 days prior to the seminar)**

Your credit card receipt will be faxed to your office. You are not registered until we receive payment in full. We will CALL your office for your  Credit Card information and Confirm your PAID reservation at that time.

Chirohealth Educational Seminars
P.O. Box 85
Gates Mills, Ohio 44040-0085
Course Chairman: Alan L. Palgut, D.C.
Seminar information: 440-306-8666
Fax: 440-306-8665