Advanced Training in Patient Activation and Engagement

Advanced Training in Patient Activation and Engagement:

Challenging Patient Relationships in Primary Care

Registration Form

Friday, September 27, 2013

8:00 a.m. – 5:00 p.m.

At

UMASS Medical School

333 South Street, France Conference Room

Shrewsbury, MA

Tailored to primary care and community health center provider needs

Practice that goes beyond the basics of working with challenging patients

Registration Fee (non-refundable) -- $25.00

A light breakfast and full lunch will be provided

Name:

Job Title:

Professional License #: License Type:

Practice Name:

Practice Address:

City/State: Zip:

Practice Telephone #: Cell Phone #:

E-mail:

If you have special dietary needs, please indicate these in the space below:

Description

pLEASE EMAIL your COMPLETED REGISTRATION FORM TO by Monday, August 12, 2013

$25 Registration Fee -- Payable by Check to:

UMASS Medical School/CFDC

Mail to:

Susan Foley

Clinical Faculty Development Center, Department of FMCH

55 Lake Avenue North, Benedict Bldg, Suite A3-182

Worcester, MA 01655

774-442-6784 (phone)