Simple Practices for Complex Times

ALL ARE WELCOME - PHYSICIANS AND HEALTH TEAM/OFFICE STAFF

We have received many requests from our physicians to include your Health Team/Office Staff in the Virtual Mindfulness Group: Simple Techniques for Complex Times, a virtual program. We welcome you to invite your Health Team/Office Staff to participate. Please complete the registration information for Team member(s) in the fields below. Once registered each Team Member will receive their own Confirmation.

Please Note: if more than 1 person is registering for the program, all registrations must be included on this form.  If you register a member of your office team please make sure to use their email address so that they receive a confirmation email. If you wish to register more than two Office Team members please contact Nicole at - 516-277-4326.
Please enter Physician registration information in the fields provided below.

Question Title

* 1. First Name:

Question Title

* 2. Last Name:

Question Title

* 3. Email: 

Question Title

* 4. Specialty

Question Title

* 5. Organization

Question Title

* 6. Designation:

Question Title

* 7. Who is your Medical Malpractice Insurance Carrier

Question Title

* 8. How did you learn about this program?  Please select all that apply

Please enter Heath Team/Office Staff registration information in the fields provided below.

Question Title

* 9. First Name

Question Title

* 10. Last Name

Question Title

* 11. Email

Question Title

* 12. Title

Question Title

* 13. First Name

Question Title

* 14. Last Name

Question Title

* 15. Email

Question Title

* 16. Title

( Privacy & Cookie Notice

T