Genetics in Primary Care

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Genetics in Primary Care: A Brown-Oxford Transatlantic Videoconference REGISTRATION FORM Date: Time: Locations: April 10, 2003 8 am – 2 pm EST (Providence) / 1 pm – 7 pm GMT (London) (1) George Auditorium, Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02905, USA* (2) Cancer Research UK Video Conference Facility, 6-10 Cambridge Terrace, London, NW14JL, UK** This conference is funded by National Cancer Institute grant #1 R13 CA101634-01, The Brown University Center for Primary Care and Prevention, and by Memorial Hospital of Rhode Island. Please complete the fields below and forward with registration fee to: Dr. Sean P. David Genetics Conference Brown University Center for Primary Care & Prevention 111 Brewster Street, Pawtucket, RI, 02860, USA Fax #: (401) 729-2494 (if paying by credit card) Title: First Name: Last Name: Address: __Dr __Prof __Mr __Mrs __Ms Position: Organization: Telephone #: Fax #: Registration Fee Payment Method: __Check (please make checks payable to Brown University Center for Primary Care & Prevention) Email: __Credit Card CC Type: __Master Card __Visa REGISTRATION FEE: $25.00 (US) *Memorial Hospital of Rhode Island is accredited by the Rhode Island Medical Society to sponsor intrastate continuing medical education for physicians. Memorial Hospital of Rhode Island designates this educational activity for a maximum of six (6) Category I credits towards the American Medical Association Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational experience. **PGEA Approved Credit Card #: Expiration Date: Payment Amount: Cardholder’s Signature:

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