Physician Wellness Small Group Learning Program Registration

1. Select Available Session:

2. Contact Information

3. Have you had previous experience with Practice Based Small Group Learning (PBSGL) with the Foundation for Medical Practice Education (McMaster)?: *

yes, was a previous PBSG member yes, attended an AdHoc PBSG workshop yes, during my residency program no, have no experience with PBSG

4. Number of years in practice: *

0-5 years 6-10 years 11-15 years 15+ years

5. With respect to your main patient care setting, describe the population primarily served by you in your practice. Please check only one: *

Inner city Urban/Suburban Small town/Rural Geographically isolated/Remote Other

6. Please indicate how your main patient care setting is organized. Please check only one. *

Solo practice Interprofessional practice [physician(s) with other health professional(s)] Group practice Other

7. How did you hear about this program? *

Email (CFPC info digest) Social Media Referral Other

Price: $99.00

Tax: $12.87

Total Amount: $111.87

Price: $99.00

Tax: $4.95

Total Amount: $103.95

Price: $99.00

Tax: $14.85

Total Amount: $113.85

Price: $99.00

Tax: $14.83

Total Amount: $113.83