Activity Evaluation and CME Credit Claim Form

Activity Evaluation and Credit Claim Form

Instructions: The information you provide on this form is indicative of your participation in this activity. Your responses will only be shared with presenters and planning committee members in aggregate format. Upon completion of the form, you will be directed to submit your evaluation. Once you have submitted your responses you will be redirected to a new page to claim your CE/CME credit and receive your certificate..

Step 1 of 2

Attendee Name*
First Last
Degree or Designation?*
Lciense Number*
Untitled
Attendee Email Address*
Attendee Phone Number*
City & state of practice (or residence if not currently in practice)
Number of Credits You Are Claiming