June 10 Buprenorphine Waiver Training Registration

HFM Farley Conference Room

757 S Clinton Ave. Rochester NY

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* 1. Name (first & last)

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* 2. Professional Degree

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* 3. Discipline

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* 4. Email address

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* 5. Your contact number

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* 6. Office Name

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* 7. Office contact name

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* 8. Office contact phone number

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* 9. Are you a resident?

Yes

No

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* 10. Are you an AHP member?

Yes

No

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* 11. Is your practice in a rural area?

Yes

No

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* 12. Is your practice in a medically under-served community?

Yes

No

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* 13. Are there any specific questions you would like to be addressed at this training?

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* 14. Food will be served at the training - do you have any dietary restrictions?