1 Start 2 Complete Title of Activity * First and Last Name * Email Address: * Profession: * Physician Nurse Nurse Practitioner Physician Assistant Psychologist Social Worker Optometrist Dentist Pharmacist Dietitian As a member of the Physician target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Nursing target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Nurse Practitioner target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Physician Assistant target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Psychologist target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Social Worker target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Optometrist target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Dentist target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Pharmacist target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. As a member of the Dietitian target audience, I agree that the information within the activity pertains to my individual profession within this IPCE activity which is designed by the team, for the team. I agree that no further changes must be made to include my profession's unique scope of practice. * Yes No Completion of the line below serves as the electronic signature and indicates that I have read and completed this form myself. * First and Last Name Today's Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20232024202520262027202820292030 Leave this field blank
