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Full Name: Street Address: City: State: Zip: Day Phone: Email Address: Seminar Date August 25th - San Jose Clinic September 8th - San Ramon September 10th - Walnut Creek September 16th - San Jose Clinic October 13th - San Ramon October 21st - San Jose Clinic November 10th - San Ramon November 18th - San Jose Clinic December 8th - San Ramon December 16th - San Jose Clinic Number of People Attending How did you hear about this seminar?      Please select one RSC Web site Integramed America Web site RSC email announcement My physician (specify name) Friend Established RSC patient Radio Ad KKSF Ad KKIQ Ad Benicia Herald Ad Contra Costa Times Ad Daily Review Ad Fairfield Daily Republic Newspaper Ad Fremont Argus Ad Modesto Bee Ad Napa Valley Register Newspaper Ad Oakland Tribune Ad San Jose Mercury Ad San Ramon Valley Times Ad Tri Valley Herald Ad Vallejo Times-Herald Newspaper Ad West County Solano Times Newspaper Ad Other (please specify)   Please enter additional information below I would like to be emailed updates from RSC Bay Area Yes No     = Required

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