Illinois State Medical Society

Practice Manager Seminars

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Registration Form

Event:

Prefix:

First Name:

M.I.:

Last Name:

Suffix: (Jr., Sr., III, etc.)

Degree:

If other please specify:

Address 1: (Suite/Floor/Room)

Address 2: (Street)

City:

State:

Zip:

Daytime Phone:

Fax:

E-mail:

Seminars are free of charge to member-managers, the practice-managers of ISMS members. Non-member managers must pay a $25 registration fee.

Is your physician employer an ISMS member?	Yes No

Please list the first and last name of the physician/s for whom you work. Please separate names with a comma.

If you are unsure about the membership status of your physician employer/s please contact Sarah Bleeden at 1-800-782-4767, ext. 6525 or at sarahbleeden@isms.org.