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Harris County Academy of Family Physicians Meeting Reservation
Complete the form below to submit your reservation for the upcoming Harris County Academy of Family Physicians meeting.
Registrant Information
First Name
*
Last Name
*
Degree:
*
DO
MD
Student
Membership Type
AAFP/TAFP Membership is
required
for medical students
*
HCAFP Member
Resident Member
Non-Member
Student Member
Email Address
*
Current Residency Program/Medical School
Baylor Residency
Memorial Hermann Southwest
Houston Methodist Residency
HCA Houston Healthcare West
UT Houston Residency
Baylor College of Medicine - Medical School
UT Houston Medical School
U of H College of Medicine
Year
PGY 3
PGY 2
PGY 1
MS 4
MS 3
MS 2
MS 1
Will you be attending the Medical Student Social Hour starting at 5:30pm?
*
Yes
No
Please select your entrée:
*
8 oz. Filet Mignon
Perry's Famous Pork Chop
Cedar Plank Redfish
VEGETARIAN - Spaghetti Squash Primavera
VEGAN - Spaghetti Squash Primavera
Dietary Restrictions:
Are you bringing a guest?
*
Yes
No
Guest Info: Guest fees must be paid in advance by calling 713-524-4267, or at the meeting. Fees are $35 for clinician guests of HCAFP member physicians, and $10 for clinician guests of HCAFP member residents/students.
Full Name of Guest:
*
Professional Type of Guest
*
Physician (MD)
Physician (DO)
Nurse (RN)
Nurse (APN)
Nurse (LPN)
HCP - Other
Physician Asst
Please select your guest's entrée:
*
8 oz. Filet Mignon
Perry's Famous Pork Chop
Cedar Plank Redfish
VEGETARIAN - Spaghetti Squash Primavera
VEGAN - Spaghetti Squash Primavera
Dietary Restrictions:
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