Registration Form

Title
---MsMissMrsMrDr

First Name*

Last Name*

Organization*

Address*

Address Line 2

City*

Province/State*
---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Postal Code/Zip*

Country*
---CanadaUnited States

Phone*

Email*

Profession*
---Diabetes EducationDietitianDoctorGeneral PractitionerInternal MedicineMedical SpecialistNurseNurse PractitionerPharmacistPhysician AssistantPrimary Care PhysicianResearch CoordinatorSpecialistOther

If other, please specify

Event Location*
---VancouverOttawa

Registration Type*
---Registration $190.00Student Registration $65.00

Total $
CAD(Includes 13% HST)

Credit Card Information

Name on Credit Card*

Credit Card Number*

Expiration Month*
---010203040506070809101112

Expiration Year*
---2018201920202021202220232024202520262027202820292030203120322033

CVV Code*

I have read and agree to the terms of the privacy policy*

Yes, I would like to receive communications from Hypertension Canada

You can review and update your personal information at any time by emailing [email protected] (opens new window)

We only collect personal information relevant and necessary to our programs and services, which include:

• Membership with Hypertension Canada, upon sign up
• Our monthly electronic newsletter, eINFO, upon sign up
• Our professional education programs, upon registration:
  • PEP (Professional Education Program) online learning modules
  • Primary Care Days CME Program
• Our annual Canadian Hypertension Congress, upon registration or abstract submission
• Our educational materials, upon placing an order
• Donations made via Canada Helps, upon donation

We collect information fairly and lawfully, and directly from individuals wherever possible to ensure we do so accurately. At this time, we collect personal information through the activities listed above, through the method(s) you choose (via website, mail, phone, fax or verbal request) to request them. Please refer to our privacy policy.