CSA Application | Helms Medical Institute

Course Application:
Chinese Scalp Acupuncture
(and optional Graduate Refresher)

Bolger Conference Center | Potomac, MD
Sat June 21: one-day Chinese Scalp Acupuncture workshop
Sun June 22: optional add-on half-day Graduate Refresher

In addition to completing this form, the following items are required for your application to be considered. You should submit them via email to mafp@hmieducation.com.

Tuition payment
Scan of your current medical license
Brief statement on your current use/practice of acupuncture

The fields indicated with an asterisk (*) are required.

Name And Professional Information

First Name*

Nickname (if applicable)

Initial

Last Name*

Degree*

State Issuing Medical License*

State Medical License Number*

Specialty 1*

Specialty 2

Year completed the Med. Acup. for Physicians (MAFP) Course*

Contact Information

Primary Email*

Military personnel and government employees must list a non-work email address for their 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.

Tuition*

CSA Course Tuition: $1125Optional add-on half-day Graduate Refresher Tuition: $350

Indicate method of payment:*

Credit Card - onlinePay online at https://mkt.com/hmiCredit Card - by phoneCall 510-649-8488 between 9:00 AM and 2:00 PM Pacific Time

All training activities will take place at the Bolger Conference Center (Potomac, MD) where a group rate of $190-210 (+ tax) has been arranged. A conference day use fee of $89 per day is required of participants who choose to stay elsewhere or room with another course participant. Reservation information will be provided upon acceptance to the course. 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.