Urban Poling Hospital Tour

* First name

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* Last name

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* Job title

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* Email

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* Phone number

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* # of sites participating in VIRTUAL presentation

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* Approximate # of patient visits per site/month

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* Specify Activator presentation topics

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* Preferred presentation dates/time (with time zone)

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* Hospital name for shipping of demo poles

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* Address

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* ZIP/Postal

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* Country

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* State/Province

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Other information or questions?

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Urban Poling Inc. | P.O. Box 85 | Embrun, ON K0A 1W0 CA

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