TAHTS Health Fair Physician Registration Form
Event Timing: October 22nd, 2022 from 9 AM to 1 PM

Please fill out the form in order to register as a Physician for the 2022 TAHTS Health Fair on October 22nd, 2022.
Thank you for volunteering your time!
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Email *
Do you have a current active license in North Carolina that does not expire prior to the day of Health Fair (October 22nd, 2022)? *
First Name *
Last Name *
Middle Name
Email *
Phone Number
Please enter the phone number in format: ###-###-####
Address *
Specialty
Language Spoken? *
Required
Physician Guidelines
Please arrive at the health fair 15 minutes before the start of the event and sign up at Physician Registration Desk.
        Collect your ID badge if you have pre-registered on web site.
 
There will not be any Practice banners at the health fair. As there may be more than one physicians in one booth, no
        practice banners will be allowed at the health fair. You may bring your business cards to give to patients.

Prescriptions will not be issued at the health fair.

Your sign up will be for 4 hours (from 9.00 AM - 1.00 PM)

For a specialty booth -  In case if you are unable to volunteer, please arrange for your replacement and notify us.

Consultation will be entertained for those with a wrist band only. The wrist band confirms that they have signed the
        waiver agreement.
I agree with Health Fair Physician Guidelines *
Electronically signed by (Type your name)
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