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Language
English - United States (en_us)
English (en)
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Speaking engagement request form
Organization
Contact Person
Date
Audience Number Expected
<10
10 - 25
26 - 75
> 76
Topic
Adverse Outcomes
Cognitive Fields
Communication
Concerning Practice Situations
Electronic, EHR, Telehealth
General and Wide Interest
Human Resources
Legal
Practice Management
Specialty Specific (not all specialties offered)
Surgery and Procedures
Wellness and Burnout
Other (Please Specify in Topic)
Requested Course Topic
Format
In-Person
Virtual (Zoom, Teams, etc.)
Both
Can you provide display for laptop PowerPoint; microphone if necessary?
Yes
No
Physical Location (if applicable.)
Whose virtual platform will be used?
COPIC’s Platform
Facility’s Platform
Other
Is your organization/practice COPIC insured?
Yes
No
*
- required
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