Event Registration Form

The 17th Annual Clinical Update for the Comprehensive Ophthalmologist

Enter your information below. This web registration form will be sent to the Clinical Update Meeting event committee when you click the "Submit Registration" button at the bottom of the page. If you have any questions about this form or problems completing it, please email ssmith@uthsc.edu, or call Shirley Smith at 901-448-5883.


                      Full Name:    
                         Degree:    
                      Specialty:    
                 Street address:    
                 City/State/Zip:    
                  Email address:    
           Daytime phone number:    
                     Fax number:    

                      Check one:     Physicians -- $230
                                     Technicians -- $125
                                    Make checks payable to: 
                                        The University of Tennessee Health Science Center
                                    Send checks to:
                                        The Hamilton Eye Institute
                                        Attn: Ms. Shirley Smith
                                        930 Madison Avenue, Suite 470
                                        Memphis, TN 38163      
   Do you have any special needs?    Mobility
                                     Hearing
                                     Vision
                                     Dietary
          If so, please describe:   

Click here to complete your registration: