Lymphedema Management

A division of Pacific Therapy Education, Inc.

Mail-In Registration Form

Name:_________________________

Course Location and Date:___________________________________

Home Address:__________________

______________________________

City:__________________________ State:__ Zip:_________

Phone: (____)_____-__________ Fax: (____)_____-__________

E-Mail:__________________

Facility:________________________

Address:________________________

_______________________________

City:___________________________State:__ Zip:________

Phone: (____)_____-__________ Fax: (____)_____-__________

Circle one please: PT OT MD

Please Enclose a check or money order payable to:

Anne-Marie Vaillant Newman, MA, PT
PO Box 2510
Cupertino, CA 95015-2510
Fax: 1 (650)898-1771
Tel: 1 (951)347-0362

Important: Confirmation of registration will be mailed with pre-course material.