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You must have JavaScript enabled to use this form. Contact information First name Last name Phone: Please format your phone number with +1 at the start. Example: +1 519-646-6100 Type - Type -HomeOfficeCell Phone Ext: Email Organization: Mailing Address: Do you require accommodations? Yes No Do you have any special requests? Year of study: - Select -PGY-3PGY-4PGY-5Other (please enter) Please specify other year of study: Specialty role: - Select -NeurologyPhysical Medicine & RehabilitationOther (please enter) Please indicate your specialty: Registration Payment (Residents) $500.00 Online payment will be processed through PayPal. Once you select the submit button, you will be redirected to the PayPal website to enter your credit card information. You do not need to have a PayPal account to complete the payment online, once redirected to PayPal, select to check out as a guest. This personal information is being collected under the authority of the Public Hospitals Act R.S.O. 1990, CHAPTER P.40 for the purpose of contacting the sender in response to an inquiry. If you have questions about the collection of this information, please contact Privacy and Freedom of Information, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON,519-646-6100 ext. 65591.
