Informing Consumers About Health Care Quality: Printable Registration Form

Informing Consumers About Health Care Quality: New directions for Research and Action

Health Systems Research, Inc.
Attn: Martrell Kelly - Registration Payment
1200 18th Street, NW
Suite 700
Washington, DC 20036

Contact Information

First Name*
Middle Initial
Last Name*
Academic Degrees *
Job Title*
Department
Organization*
Organization*
Address*
Address*
City*
State*
Country
Zip Code*
Telephone*
Fax*
E-Mail*

Special Needs/Accommodations:
please describe:

Breakout Session I will attend at 1:15pm*: (circle one)

1 - Consumers Employed in the Public and Private Sectors

2 - Older Consumers/Medicare

3 - Consumers With Special Health Care Needs

4 - Consumers With Special Communication Needs

Breakout Session I will attend at 3:00pm*: (circle one)

1 - Consumers Employed in the Public and Private Sectors

2 - Older Consumers/Medicare

3 - Consumers With Special Health Care Needs

4 - Consumers With Special Communication Needs

Category*: (circle one)
[Consumer] -- [Health Care Provider] -- [Employer] -- [Researcher] -- [Policy Maker]

Billing Information:

Amount charged to Card	$150.00
Name as shown on Card:
Billing Address (if different than above)
City, State, Zip
Credit Card Type*
Credit Card Number*
Credit Card Expiration (mm/yy)*

Signature: ___________________________________

Print Full Name: ______________________________

Date: _______________________________________