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: Role: - Select -FellowPhysicianResidentSurgeonTherapistOther Other Role (please enter): Please indicate your specialty: Registration In person attendees: Physicians/surgeons: $300 Residents/fellows: $150 Therapists: $125 Virtual attendees: Physicians/surgeons/residents/therapists: $150 Payment type Online payment by credit card (you will be redirected to PayPal) Cheque If you wish to pay by cheque, please make payable to "Canadian Peripheral Nerve Symposium" and remit by mail to: ATTN: Douglas Ross Division of Plastic Surgery St. Joseph's Health Care London PO Box 5777, STN B London, ON N6A 4V2 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.
