Discover the Myofunctional Therapy Puzzle

Date of Registration(Required)

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

E-mail(Required)

Please select your current professional credentials (mandatory to attend course).(Required)

Emergency Contact with phone(Required)

Food Allergies or requests(Required)

Please Contact Us for Any Special Accommodation Needs

Why are you interested in this course?(Required)

What are your goals post-course?(Required)

Please select locations and dates(Required)

Payment of the $2,800 course fee is due at time of registration. Your registration is not complete until payment has been received.(Required)

I acknowledge

Accepted forms of payment include: payment via Zelle to Chase Bank at 847-207-7463 with no additional fees, personal check or certified check paid immediately after registration within 5 days of registration you (must contact Pat if using personal check).

Printed Name

First Name Last Name

I understand, that I am a licensed professional registering for a 4-day 30-hour course on "Discovering the Myofunctional Therapy Puzzle." Please digitally sign:(Required)

Once You Finish Registration, Payment is Also Due

Thank you for registering. Finish by paying safely and securely

Pay by Zelle at Chase Bank at Muscles and Harmony / (847) 207 -7463

Additional 4% fee will be charged.