WebAIH

Title * :

First Name * :

Middle Name:

Last Name * :

Profession * :

Chiropractor	Dentist	Osteopath
Chiropractor Student	Nursing Student	Dental Hygiene Student
Craniopath	Medical Doctor	Medical Student
Dental Assistant	Massage Therapist	Professional Development
Dental Hygienist	Naturopath	Registered Nurse
Dental Student	Orthodontist	Acupuncturist
Other

Hotel Room Sharing request:

Yes No

Practice Address * :

City * :

State/Province * :

Zip/Postal Code * :

Country * :

Practice Phone * :

Fax:

Mobile Phone:

Email Address * :

Accurate and up-to-date Email addresses are very important. They are essential when participating within Q&A, Discussion Forum, and Case diagnosis, as this is how you will be notified of new content, responses to your questions and case reviews.

Your Office Website:

http://

Cost:

Part One - Academy of Integrative Health™
Integrative Health Consultant Certification $595.00

Location/Date:

* Note: 20% of registration fee will be
kept upon cancellation

Course Location *

Date of 3 day Course *

Registered		Title
Registered		Title
Registered		Title

Are you an Integrative Health Practitioner? * :

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Are you new to Integrative Health? * :

Yes No

Areas of Wellness interest: * :

Are you interested in Integrative Health Certification of all 3 levels? * :

Yes No

* Asterisks indicate a required field.