* = Required Field

REGENETEN Surgeon Choice 1:*
Dr. Jeffrey Abrams, Princeton, NJDr. Amin Nirav, Loma Linda, CADr. Steven Arnoczky, East Lansing, MIDr. Christopher Baker, Temple Terrace, FLDr. Stacy Beaty, San Angelo, TXDr. Shariff Bishai, St. Clair Shores, MIDr. Jonathan Bravman, Golden, CODr. Brandon Bushnell, Rome, GADr. Paul Favorito, Cincinnati, OHDr. Michael Freehill, Ann Arbor, MIDr. Mark Getelman, Thousand Oaks, CADr. Lawrence Gulotta, Chappaqua, NYDr. Howard Harris, Bedford, TXDr. Thomas Knapp, Santa Monica, CADr. Ron Koe, Las Vegas, NVDr. Marc Labbé, The Woodlands, TXDr. Ferdinand Liotta, Glenwood Springs, CODr. Louis McIntyre, Sleepy Hollow, NYDr. Sean McMillan, Burlington, NJDr. Lee Murphy, Montgomery, ALDr. Chris O'Grady, Pensacola, FLDr. Howard Routman, Palm Beach Gardens, FLDr. Richard Ryu, Santa Barbara, CADr. Felix Savoie, New Orleans, LADr. Scott Sigman, North Chelmsford, Chelmsford, MADr. Scott Trenhaile, Rockford, IL

REGENETEN Surgeon Choice 2:*
Dr. Jeffrey Abrams ,Princeton, NJDr. Amin Nirav, Loma Linda, CADr. Christopher Baker, Temple Terrace, FLDr. Stacy Beaty, San Angelo, TXDr. Shariff Bishai, St. Clair Shores, MIDr. Jonathan Bravman, Golden, CODr. Brandon Bushnell, Rome, GADr. Paul Favorito, Cincinnati, OHDr. Michael Freehill, Ann Arbor, MIDr. Mark Getelman, Thousand Oaks, CADr. Lawrence Gulotta, Chappaqua, NYDr. Howard Harris, Bedford, TXDr. Thomas Knapp, Santa Monica, CADr. Ron Koe, Las Vegas, NVDr. Marc Labbé, The Woodlands, TXDr. Ferdinand Liotta, Glenwood Springs, CODr. Louis McIntyre, Sleepy Hollow, NYDr. Sean McMillan, Burlington, NJDr. Lee Murphy, Montgomery, ALDr. Chris O'Grady, Pensacola, FLDr. Howard Routman, Palm Beach Gardens, FLDr. Richard Ryu, Santa Barbara, CADr. Felix Savoie, New Orleans, LADr. Scott Sigman, North Chelmsford, Chelmsford, MADr. Scott Trenhaile, Rockford, IL

Meeting Time:*

Sales Rep Name:*

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Sales Rep Cell Phone:*

DOS/TM or TM Name:*

City for Symposia:*

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Additional Comments:*

  Sales Rep or MDM’s will create the invitation for the Dinner Symposia.

  I understand that sales rep is responsible for booking and paying for dinner.

  Faculty is in my region.

  Please confirm you have read below:
I understand that this date is NOT confirmed until I receive notice from Michelle Turner.

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