Register Now!

Congratulations on taking the first step on your journey to a happier, healthier life. Please fill out the form below to reserve space at the specified seminar. You will then receive an email confirming that your request has been submitted, and space will be saved for you and your guests at our seminar.

Seminar Details

Date and Time of Seminar July 30, 2010, 11:30 AM - 12:30 PMJuly 30, 2010, 11:30 AM - 12:30 PMAugust 6, 2010, 11:30 AM - 12:30 PMAugust 13, 2010, 11:30 AM - 12:30 PMAugust 20, 2010, 11:30 AM - 12:30 PMAugust 20, 2010, 11:30 AM - 12:30 PMAugust 26, 2010, 5:30 PM - 6:30 PMAugust 30, 2010, 5:30 PM - 6:30 PM

Title: Banner Estrella Medical Center, Conference Center (Across from Main Hospital Lobby), 9201 W. Thomas Road, Phoenix, AZ 85037, Call 480-577-8724 for more information!

Where:

Banner Estrella Medical Center, Conference Center (Across from Main Hospital Lobby), 9201 W. Thomas Road, Phoenix, AZ 85037, Call 480-577-8724 for more information!

REGISTER NOW

Patient Information

Date of Birth * - month - JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember - day - 12345678910111213141516171819202122232425262728293031 - year -1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010

Height * feet inches

Weight * pounds

First Name *

Last Name *

Gender * -- select a gender --MaleFemale

Contact Information

Address 1 *

Address 2

City *

State * -- select a state -- AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Country United States of America

Primary Phone *

Alternate Phone

E-mail Address *

Others

Insurance

Number of Guests* --- 01234

 

Please type the letters as shown*