A practice management consulting and training firm working for and with physicians since 1985

E&M Profile Analyzer for Otolaryngology (Group Version) Order Form

Please Provide the Following Information
*Product Ordered*
* Practice
*Title*
* First Name
Middle Initial
* Last Name
* Address
* Address 1
* City
* State	*Zip
* Work Phone
* FAX
* E-mail
This product is available through a licensing agreement with the AMA. Compliance with our agreement requires answering the following question
This product is licensed and for use in the United States and it's territories. Will this product be used in the United States and/or it's territories?
How many people will access and use this product?
Will this product be used by a U.S. Governmental Agency?


* Required Fields
*Pay By Check?*	Yes Check this box if you plan to send a check by U.S. Mail. We will hold your space for five business days while we await payment. Click the Continue button below to email your registration.
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KarenZupko & Associates, Inc. • 625 North Michigan Avenue, Suite 2225 • Chicago, Illinois 60611 • 312.642.5616 • FAX: 312.642.5571