The Austin Diagnostic Clinic: Let Our Family Care for Your Family

Health Matters Registration Form
To register for an ADC class please fill out the form below and submit.

Registration Information

    First Name:  required
     Last Name:  required
Street Address: 
   Apt. Number: 
          City: 
         State: 
      Zip Code: 
     Telephone:  required
           FAX: 
        E-mail: 
  Including yourself, how many will attend?
                
Classes:
Select a class:

     Peripheral Artery Disease - Wednesday, March 21, 2012

Submit a Question for the Doctor:
The providers will address as many questions as time allows. Questions will be submitted to the team anonymously.

How did you hear about this class?

Form Submission

You've done it! You are now registered for an ADC class or seminar.  
Due to the number of incoming registrations we are unable to confirm registrations
by phone.  You will be notified by phone or email in the event of a cancellation.


repstein@adclinic.com
Copyright © 1995 The Austin Diagnostic Clinic. All rights reserved.
Revised: February 03, 2012.
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