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Step 1 of 10 10% Training Date*February 21-22 Evexias Corporate Office (Southlake, TX)March 27-28 Evexias Corporate Office (Southlake, TX)May 8-9 Evexias Corporate Office (Southlake, TX)Choose your preferred training date from the drop down menu.Contact InformationPractice Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Primary Contact* First Last Phone #*Email* Who is your EvexiPEL account representative (PDS)?*What is your EvexiPEL contract level?PartnerSilverGoldPlatinumHow many total Practitioners will attend this hormone pellet therapy training?*01234How many total Office Staff will attend this hormone pellet therapy training?*01234Has any practitioner from your practice ever attended EvexiPEL training?*NoYes NEW Practitioner (Partner Contract Level)A new practitioner is someone who has never been trained by EvexiPEL.Name* First Last Medical Credentials Email* Cell Phone #*Training Type*New - Never been to EvexiPEL trainingRefresher - Attended EvexiPEL training in the pastAdvanced - Have pellet therapy experience, but not EvexiPEL trainedChoose one from below: New PractitionerA new practitioner is a practitioner who has never been trained by EvexiPEL.Name* First Last Medical Credentials Email* Cell Phone #*Training Type - Choose one:*New - Never been to EvexiPEL trainingRefresher - Attended EvexiPEL training in the pastAdvanced - Have pellet therapy experience, but not EvexiPEL trained Practitioner RegistrationA practitioner in your clinic has been trained by EvexiPEL.Name* First Last Medical Credentials Email* Cell Phone #*Have you been trained by EvexiPEL?*NoYesTraining Type - Choose one:*New - Never been to EvexiPEL trainingRefresher - Attended EvexiPEL training in the pastAdvanced - Have pellet therapy experience, but not EvexiPEL trained Additional Practitioners AttendingName* First Last Medical Credentials Email* Cell Phone #*Have you been trained by EvexiPEL?*NoYesTraining Type - Choose one:*New - Never been to EvexiPEL trainingRefresher - Attended EvexiPEL training in the pastAdvanced - Have pellet therapy experience, but not EvexiPEL trained Office Staff Registration #1Name* First Last Title/Position Email* Cell Phone #* Office Staff Registration #2Name* First Last Title/Position Email* Cell Phone #* Office Staff Registration #3Name* First Last Title/Position Email* Cell Phone #* Name* First Last Title/Position Email* Cell Phone # Hotel AccommodationsTraining begins at 9am on Friday and is over approximately 4pm on Saturday. Please let us know if you will require hotel accomodations at the conference hotel (Marriott Solana- Westlake Tx). Room sharing is encouraged.Will you require a hotel room(s)? If yes, please provide guest names and travel dates below.* Yes No Room 1 First Person Name Second Person Name Check-in DateCheck-out DateRoom 2 First Person Name Second Person Name Check-in DateCheck-out DateRoom 3 First Person Name Second Person Name Check-in DateCheck-out DateRoom 4 First Person Name Second Person Name Check-in DateCheck-out DateRoom 5 First Person Name Second Person Name Check-in DateCheck-out DateMealsAll meals are included in the training fee. So that we may accommodate all parties, please indicate below what meals you will be participating in.Will you be joining us for lunch on Friday at 11am?*YesNoHow many?*Will you be joining us for cocktails and dinner on Friday at 6:30pm?*YesNoHow many?*Will you be joining us for breakfast on Saturday morning at 6:45AM-7:15AM?*YesNoHow many?*Training ScheduleFriday - Registration 8:30AM; Training sessions 9:00AM - 5:00PM; Saturday - Training sessions 7:30AM - 4:00PMYou're registration is COMPLETE! Thank you for partnering with Evexias Health Solutions! You'll receive detailed information in the coming days with regards to lodging and timing of the sessions. In the meantime, please don't hesitate to contact Terri Coplin (terri.coplin@evexias.com) should you have immediate questions or require assistance. We're looking forward to a great training!
