Name And Professional Information

First Name*

Nickname

Last Name*

Pronouns*
She/Her/HersHe/Him/HisThey/Them/TheirsOtherPrefer not to respond

Date of Birth*
JanFebMarAprMayJunJulAugSepOctNovDec1234567891011121314151617181920212223242526272829303120052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Degree*
MDDOPANPDDSDMDOther

State Issuing Medical License*

Medical License Number*

Specialty 1*

Specialty 2

Contact Information

Primary Email*

Work Email

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Personal Phone*

Please use the format 555-555-5555 for US phone numbers.

Work Phone

Please use the format 555-555-5555 for US phone numbers.

Additional Guidelines*

Model/Partner Requirement:*
By checking here, you acknowledge the requirement to have a model/partner available from 3:30-5pm ET (12:30-2pm PT) the day of the workshop. This partner must be an adult, may not be pregnant, and consents to having their ear inspected, scanned, and needled.
State Practice Requirements:*
By checking here, you acknowledge it is your responsibility to ensure this course fulfills training and practice requirements for your state.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com. Once you have submitted this online application you will receive a confirmation email.