Piedmont Crossing

Clinic Form

Thank you very much for offering to present a clinic at the upcoming MER Convention.

Below you will find a form that will provide us with most of the information we will need to schedule and publicize your clinic.

We are going to try to copy the information directly from the completed form to the web page and convention booklet. To enter information on this form, use the mouse, tab key, or arrow keys to move from one field to the other. Type in the appropriate information, or check the box.

If you have a picture associated with the clinic, please check the box "Sending Photo" and we will follow up with you. JPG format preferred. Please use the naming convention LastNameClinicTitle for both the form and the picture. You can run all the words together using capitalization to indicate the beginning of a word or use an underscore, but please no blanks in the names.