Connecticut Orthopedic Society

CONNECTICUT ORTHOPEDIC SOCIETY MEETING REGISTRATION FORM

Programs & Seminars | Annual Meeting | Registration Form

You can fill out this SECURE Online form or you can print, fill out and mail with your check or credit card info to:

Connecticut Orthopedic Society
Susan Schaffman - Executive Director
26 Riggs Avenue
West Hartford, CT 06107
PHONE: (860)561-5202
FAX (860)561-5514
Email: sasshops@aol.com

I (we) will attend the program

Attendee Name

Practice

Practice Manager’s

Address

City ST Zip

Telephone

Fax

E-mail
(For registration confirmation purposes)

Credit Card Information

Name on Card

Type of Card

MC or Visa

Account No.

Expiration Date

Amount billed to your account will be $100.00