Cognimed.net

CME Certificate Registration
To enable us to measure the quantitative and
qualitative effectiveness of this continuing medical
education program, we ask that you take a few
minutes to complete the certificate registration
below prior to this activity and the CME evaluation
and postprogram questionnaire upon activity
completion.

Your certificate for continuing education credit (if
applicable) will be issued from the following
information and upon completion of the evaluation
after review of the activity.

An asterisk (*) indicates a required field.
*First name:		MI:
*Last name:
*Degree(s):
Degrees (additional):
Title:
*Specialty:
Specialty (other):
Years in practice:
*Affiliation:
Department:
*Practice type (please check all that apply to your practice):	Clinic Home care Hospital-based Long-term care Private practice University-based Other (please specify)
Practice type (other):
Address:	Business Personal
Address name:
*Address 1:
Address 2:
*City:
*State:
*ZIP:
*Daytime phone:
Ext:
Fax:
*E-mail:
Date of birth:	(for record-keeping purposes only)
	Because you have attended or shown interest in our programs, we may send you information on this and similar programs utilizing the e-mail address provided. You may unsubscribe at any time by clicking on the “unsubscribe” link on any e-mails received from us. Please do not send me information via e-mail. We value the confidentiality of the information you choose to share with us and are committed to its protection. All personal information you provide is stored in a secure location and will never be sold or distributed to any third party.