Request a session here!

Physician Peer Education Project on Immunization session request form

If you would like to request a 1 hour immunization lecture for your facility, please complete the following form. Once your form has been submitted, you will be contacted to finalize the date(s) and other details.

If you would prefer to submit this form via fax, please print and complete this form and fax to: 517-355-6748.

Please fill out the form below:

Contact Person:*
Organization:*
Address:*
Phone number (including area code)*
Email address:
Fax number (including area code):
Preferred method of contact:	Phone Email
Will be the primary audience be physicians, medical students, conference attendees, or residents?*
Do you have a preferred date and/or time? If so, please describe.
Which module would you like?
Would you like us to provide CME?
Do you have audio/visual equipment (i.e. computer with PowerPoint and projector) available?
Do you have any additional information you would like to provide?
Submit
* Required