VBF Super Clinic 2024 - NYC

2024 VBF Super Clinic - NYC Registration Details

Registrant Name and Address

 
 
Please note that we are unable to assist in securing a visa to the US. If you need a visa, please contact your embassy to find out requirements.
 

Please tell us about the patient who will be attending the conference

 

Please tell us about your birthmark so that we can provide the most appropriate services.

Who are the patient's current physicians? (add up to 3)


Please provide a current photo clearly showing the patient's birthmark so that we can best tailor our conference services for you. (JPG or PNG please less than 5 mb in size). A photo is required and is necessary to assign you to the appropriate clinical teams. If you are unsuccessful at uploading a photo here, you must email a photo of your birthmark to info@birthmark.org. When emailing, please include in the subject line the registrant's name so that we can file appropriately.
Dental and Orthodontic exams are only for individuals with a vascular birthmark in their gums or mouth area


Additional attendees (Required)

In addition to the REGISTRANT and the PATIENT, please add up to 1 additional attendee.

Please add any additional photos or documents.

Event Fee(s)
Total
Credit Card
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Billing Name and Address
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Privacy
I have reviewed VBF's HIPAA Notice of Information Practices and Privacy Statement and hereby provide my consent.
 
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