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**First Name:
   M.I.:   **Last Name:
**Address

**City:
   **State:   **Zip:
**Phone:
Fax:
Medical Specialty:
E-mail address:
*M.E. #:
**Date of Birth:
**Medical School:
  **Year Graduation:
Additional Comments
  Yes! Send me bulk copies of the patient education newsletters for my office use.
*The Medical Education Number (ME) is an 11-digit number assigned to every physician in the US by the AMA for identification and recording of basic information. If you are an AMA member, this number is found on your AMA membership card. If you do not have your ME number, you can obtain this number by calling the AMA at 1-800-262-3211. If this is not possible, please identify your date of birth, medical school, and year of graduation so that AMA staff can look up your ME number and accurately record credits.

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