Targeted Outreach Education Project Form

Fill out the form completely and press 'submit'. You can view the TOEP brochure here.

Yes! We would like to be a part of the KAETC Targeted Outreach Education Project!

Number of People Participating:
How many of each discipline? Physicians Nurses ARNPs Physician Assistants Pharmacists Dentists Dental Hygenists Office Personnel Others

The best time for KAETC to come to our office is:
Breakfast	(time: )
Lunch	(time: )
Dinner	(time: )
Day / Date

Program Length:
We would prefer to have a full program
1 hour 1 - 1/2 hour 2 hour

Contact Information:
Practice Name
Contact Person
Address
City
State
Zip
Phone
Fax
E-mail