Name And Professional Information

First Name*

Initial

Last Name*

Preferred Name

Degree*
MDDODDSPANPOther

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*

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.

Tuition*

CSA Course Tuition: $925 (late application fee is now waived!)

Indicate method of payment:*

CheckPreferred - Payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704Credit Card - onlinePay online at https://mkt.com/hmiCredit Card - by phoneCall 510-649-8488 between 9:00 AM and 2:00 PM Pacific Time or fax to 510-649-8692

All training activities will take place at the Tempe Mission Palms Conference Center (Tempe, AZ) where a group rate of $149 (plus $11.95 hospitality fee + 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.
All particpants, HMI staff, and HMI preceptors must be fully vaccinated & boosted against COVID-19 to participate in in-person activities. Additional health and safety precautions will be implemented at the in-person teaching activities, and these measures must be followed by all attendees.
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.