i3 Health Education - Request a Meeting

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To request a meeting for your institution, complete the following Request a Meeting application. For questions, please contact Madelyne Fabrizio, Program Coordinator, at MFabrizio@i3Health.com or 973-928-8085 ext 216.

* = Required.

First Name:*

Please enter your first name.

Last Name*

Please enter your last name.

Email*

Please enter your e-mail address.

Title*

Please enter your title (Fellowship Director, CME Coordinator, etc.)

Phone*

Please enter your phone number.

Please tell us about your organization's educational needs.

Please rank the educational gap at your institution related to castration-resistant prostate cancer (1=Education Not Needed; 5=Education Very Much Needed)*

How many oncologists do you expect to attend this activity?*

Please enter a response.

How many oncology nurses do you expect to attend this activity?*

Please enter a response.

How many pharmacists do you expect to attend this activity?*

Please enter a response.

How many other health care professionals do you expect to attend this activity?*

Please provide a response.

Please let us know your preferred meeting dates and times by selecting a date within the range 10/15/19-4/30/20 from the calendars below.

Date of First Meeting Choice*

Please select a date for your first meeting choice.

Time of First Meeting Choice

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Date of Second Meeting Choice

Please select a date for your second meeting choice.

Time of Second Meeting Choice

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Date of Third Meeting Choice

Please select a date for your third meeting choice.

Time of Third Meeting Choice

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Please tell us about your meeting venue.

Meeting Location*

Please enter the name of the meeting site.

Meeting Phone*

Please enter the phone number for the meeting site.

Meeting Address 1*

Please enter the address of the meeting site.

Meeting Address 2

Please enter the address of the meeting site.

Meeting City*

Please enter the city of the meeting site.

Meeting State*

Please enter the state of the meeting site.

Meeting ZIP Code*

Please enter the ZIP Code of the meeting site.

Anti-Spam Code*

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