Splint Fab Course Attendee Info

Name *

Company Name *

North Coast Account #

Title *

Email *

Phone *

Which Splinting Educational Course did you recently attend:

Date: *

City, State *

Was this course the first time you had an opportunity to use North Coast Thermoplastics? *

YesNo

Will you consider becoming a Certified Hand Therapist? *

Yes, most definitelyMaybe, too early to tellNo, I do not expect to pursue a CHT

How many other therapists do splinting where you are currently employed? *

NoneJust one2 or 3More than 3

Are you the person responsible for choosing splinting materials and where to buy such? *

YesNo, but I can make suggestionsNo, I am not involved in those types of decisions

If No, who is the best contact where you work to discuss thermoplastics and sampling opportunities ?

Name:

Job Title:

For your free gift – please complete the following: *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry