cme_infoform

Synergy Medical Office of Continuing Medical Education Information Form

Please complete and return this form to the Office of CME at Synergy Medical.

PLEASE CIRCLE ONE:

I am a(n)

MD

DO

PhD

DDS

PA

OTHER

SPECIALTY:_________________________________

SUBSPECIALTY:____________________________

FULL NAME:________________________________________________________________________

           (first)          (middle)                     (last)

PREFERRED MAILING ADDRESS:

Organization:________________________________________________________________

Address:______________________________________________________________________

__________________________________________________________________________________

           (city)                        (state)                      (zip+4 digit)

County:_________________________________________________

Phone:______________________________

Fax:___________________________________

E-mail Address:_______________________________

Do you wish to receive the CME monthly activities calendar?    YES    NO

Do you wish to receive brochures for upcoming events?    YES    NO

Please sign below if you want to receive a summary report (CME transcript) of the conferences you attended during the year.
**Please note that there is a minimal annual fee charged by the CME Department for maintaining these records. A fee schedule is attached.

Signature_______________________________________________ Date_____________

Thank you for your time and cooperation! Synergy Medical Office of Continuing Medical Education 1000 Houghton Avenue Saginaw, MI 48602