Proper Prescribing of Controlled Substances Fields marked with an * are required Participant Information Tuition & Enrollment Terms & Conditions Participant Information Salutation * - None - Dr. Mr. Ms. Mrs. Prof. First Name * Middle Initial Last Name * Degree * - Select Degree - M.D. D.O. P.A. A.A. A.A.S. A.D. A.P.R.N. A.R.N.P. A.S. Au.D. B.A. B.D.S. B.H.Sc. B. Pharm. B.S. B.S.N. B.Sc. B.Sc. P.T. B.Sc.Pharm. B.V.Sc. C.N.M. C.Psych. C.R.N.A. D.C. D.Ch. D.D. D.D.H. D.D.S. D.M.D. D.M.Sc. D.N.A.P. D.N.P. D. Opt D.P.M. D.P.N. D.P.T. D.V.M. Dr. T.C.M. Ed.D. F.D. F.N.P. F.R.C.S.C. J.D. L.C.S.W. L.M.C.C. L.M.H.C. L.M.H.P. L.I.M.H.P. LL.B. L.M.F.T. L.M.T. L.P.C. L.P.N. M.A. M.B.A. M.B.B.S. M.B.Ch.B. M.C. M.Div. M.Ed. M.H. M.H.A. M.L.T. M.M.Sc. M.N.Sc. M.P.A. M.P.A.S. M.P.H. M.P.T. M.S. M.Sc. M.S.N. MSN-Ed M.S.W. N.D. N.P. O.D. O.T. O.T.A. P.A.C. Pharm.D. Ph.D. P.M.H.-N.P. Psy.D. P.T. P.T.A. R. Ph. R.D.H. R.D.P.N. R.M.T. R.N. R.P. R.P.N. R.R.T. Other Not Applicable What is your Primary Practice Specialty? * < Select > Abdominal Surgery Acupuncture Addiction Medicine Addiction Psychiatry Administrative Medicine Adolescent Medicine Allergy and Immunology Anatomic Pathology Anesthesiology Bariatric Medicine Bariatric Surgery Behavioral Health Breast Surgery Cardiology Cardiology - Interventional Cardiothoracic Surgery Cardiovascular Disease Cardiovascular Surgery Child/Adolescent Psychiatry Child Neurology Chiropractic Clinical Pathology Colon and Rectal Surgery Cosmetic/Aesthetic Medicine Critical Care Dental Dermapathology Dermatology Diabetes Diagnostic Radiology Emergency Medicine Endocrinology Facial Plastic Surgery Family Medicine Family Medicine - No OB Forensic Pathology Forensic Psychiatry Gastroenterology General Practice General Preventive Medicine General Surgery Geriatric Medicine Geriatric Psychiatry Gynecologic Oncology Gynecology Hand Surgery Head and Neck Surgery Hematology Hematology Oncology Holistic Medicine Hospital Medicine Immunology Immunopathology Infectious Disease Internal Medicine Massage Therapy Maternal and Fetal Medicine Medical Microbiology Medical Oncology Medical Toxicology Midwifery Musculoskeletal Oncology Neonatal-Perinatal Medicine Nephrology Neurology Neuropathy Neuroradiology Neurosurgery Nuclear Medicine Nuclear Radiology Nurse Anesthetist Nurse Midwife Nursing Nutrition Obesity Medicine Obstetrics Obstetrics and Gynecology Occupational Medicine Oncology Ophthalmology Optician Optometry Oral and Maxillofacial Surgery Orthopedic Surgery Orthopedic Surgery of the Spine Otolaryngology Otology Otorhinolaryngology Pain Management-Interventional Pain Management-Medical Pain Medicine Palliative Medicine Paramedic Pathology Pediaric Allergy Pediatric Anesthesiology Pediatric Cardiology Pediatric Critical Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology/Oncology Pediatric Medicine Pediatric Nephrology Pediatric Neurodevelopmental Disabilities Pediatric Neurology Pediatric Rheumatology Pediatric Surgery Pharmacy Physical Medicine and Rehabilitation Physical Therapy Physician Assistant Plastic Surgery Podiatry Primary Care Psychiatry Psychoanalysis Psychology Psychopharmacology Psychotherapy Pulmonary Critical Care Pulmonology Radiation Oncology Radiology Radiology - Interventional Reproductive Endocrinology Respiratory Therapy Rheumatology Sports Medicine Surgical Oncology Thoracic Surgery Trauma Surgery Urgent Care Urogynecology Urology Vascular Surgery Veterinary Other Not Available Personal Email * Work Email Country * United States Canada State * - Select State - Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Unknown Mailing Address * City * Zip * Seminar Fee The Proper Prescribing of Controlled Substances Seminar Fee is: $0.00 USD Mobile Phone * Work Phone Preferred Method of Contact * Email Phone Divider Copy Do you want to request any special accommodations during this Seminar for a medical or learning disability or limitation? If so, please describe the accommodation you are requesting. Further documentation may be requested. 255 of 255 Character(s) left Divider Copy Copy The following information is for research and grant purposes only: The following information is for research and grant purposes only: Gender < Select > Male Female Prefer not to answer Other Birthdate (MM-DD-YYYY) * Month-Day-Year format Ethnicity < Select > African African American Asian/PI Caucasian Hispanic Indian (India) Native American Not Available Other Medical/Graduate School Country United States of America Canada Afghanistan Albania Algeria Angola Argentina Armenia Australia Austria Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bolivia Brazil Bulgaria Burkina Faso Cambodia Cameroon Chile China Colombia Comoros Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Kingdom (UK) Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe Year Most Recent Professional Degree Completed? - Select - 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 If you are a human seeing this field, please leave it empty.
