Pre-Registration Form

Perry Institute On-Line Training


The following information is requested to help us design the course for the people who will actually be using it. Please send this form, even if you already indicated your interest by email to Dr. Perry; these new forms will go directly into a database.

IF your browser does not handle "forms" (i.e., it won't let you fill in the blanks), you may still be able to PRINT it now and either FAX it to 305-294-5115, or convert it to an email message and send to DrPerry@incontinet.com.


Personal Information

        First Name: 
Last Name & Degree: 
        Profession: 
       Business Name: 
      Street Address: 
                City: 
               State: 
            Zip Code:  Country: 
             Telephone: 
                   FAX: 
                E-mail: 
                   URL: 

Please select from these options:

1. Are you currently Active in the Treatment of Incontinence or PMD?:

 Very Active 
 Somewhat Active 
 It's a future plan  
 I'm Just Curious

2. Please describe your Level of Experience in Treating Incontinence (Beginner? Seen hundreds of patients? Which?):

3. Which Five (5) Topics (from our Outline) are most interesting to you?:

 History and Background     Censorship and Awareness
 The Costs of Incontinence  What is "Biofeedback"?
 Colo-rectal Evaluations    Colorectal Treatments
 Urological Evaluations     Urological Treatments
 Behavioral Treatments      The Business side of Incontinence
 The Home Trainer debate    Dealing with Special Populations
 Sexual Dysfunctions        Dealing with Resistant Cases
 Equipment Problems

4. What other or more detailed topics do you want to know more about?

5. How do you intend to use this training? What do you want to accomplish?

6. Do you know now which of the several manufacturer's systems you will be using?:


Form Submission

Click on the Pre-Register Me Now button to submit this form. There is no cost or obligation. There will be NO COST to "taking" the course. There may be a small processing fee if you want to complete quizes and obtain a Certificate attesting your accomplishment. You will be notified by personal email when the course is ready.

DO NOT Register twice! This form has to be sent to our website, processed, and acknowledged; the round-trip will take a few moments. Watch your modem status lights!

You will receive an acknowledgement. Then click here to return to our Home Page.


This page is <http://www.incontinet.com/articles/prereg.htm>.
Copyright © 1996 John D. Perry. All rights reserved.
Revised: May 04, 2005.