Opioid Epidemic & Addiction Medicine

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form to register for the event with Dr. Nicole Gastala of UI Health, scheduled for Tuesday, January 10, 2023, 12:30 - 2:00 PM CST, in SSOM 170.

As space is limited, those indicating a preference for in-person participation will secure a seat on a first come, first served basis by submission date / time of this form. The session will also be open to participation via Zoom as well.

For those able to attend in person, the session will include a boxed lunch.

Email *

First Name *

Last Name *

Please indicate how you will participate in this event: *

In person

Via Zoom

If you replied "in person," please let us know of any dietary requirements, preferences, food allergies, etc.:

If you have any questions for the presenter and / or event organizers that you would like to share before the event, please include them here:

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms