Orthotown October 2017 - 47

CONTINUING
EDUCATION
ANSWER
SHEET

Instructions: To receive credit, complete the answer sheet and mail it, along with a check or credit card
payment of $36, to: Orthotown.com Inc., 9633 S. 48th St., Ste. 200, Phoenix, AZ 85044. You may also fax this
form to 480-598-3450 or answer the post-test questions online at orthotown.com/onlinece. This written
self-instructional program is designated for 1.5 hours of CE credit by Farran Media. You will need a minimum
score of 70 percent to receive your credits. Participants pay only if they wish to receive CE credits; thus
no refunds are available. Please print clearly. This course is available to be taken for credit Oct. 1, 2017,
through its expiration on Oct. 1, 2020. Your certificate will be emailed to you within 3-4 weeks.

Changing Lives, One Airway at a Time

CE Post-Test
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Name ______________________________________________________________________________________________________

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Address ___________________________________________________________________________________________________

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by Dr. Manjari Kulkarni
License Number ______

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AGD# _____________________________________________________________________________________________________

City ____________________________________________________

State ___________

ZIP ________________________

Daytime phone _____________________________________________________________________________________________
Email (required for certificate) ______________________________________________________________________________
o Check (payable to Orthotown.com, Inc.)

Please circle your answers.

o Credit Card (please complete the information below and sign; we accept Visa, MasterCard and American Express.)
Card Number ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
Expiration Date - Month / Year ______ ______ / ______ ______ ______ ______
Signature ___________________________________________________________________________

Date __________________________________________________

Program Evaluation (required)
Please evaluate this program by circling the corresponding numbers: (5 = Strongly Agree to 1 = Strongly Disagree)
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Course administration was efficient and friendly
Course objectives were consistent with the course as advertised
COURSE OBJECTIVE #1 was adequately addressed and achieved
COURSE OBJECTIVE #2 was adequately addressed and achieved
COURSE OBJECTIVE #3 was adequately addressed and achieved
COURSE OBJECTIVE #4 was adequately addressed and achieved
Course material was up-to-date, well-organized, and presented in sufficient depth
Instructor demonstrated a comprehensive knowledge of the subject
Instructor appeared to be interested and enthusiastic about the subject
Audio-visual materials used were relevant and of high quality
Handout materials enhanced course content
Overall, I would rate this course (5 = Excellent to 1 = Poor):
Overall, I would rate this instructor (5 = Excellent to 1 = Poor):
Overall, this course met my expectations

Comments (positive or negative):

5
5
5
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5
5
5
5
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5
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5
5
5

4
4
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3
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3

2
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2
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1
1
1
1
1
1
1
1
1
1
1
1
1
1

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For questions, contact Director of Continuing Education Howard Goldstein at hogo@dentaltown.com.

orthotown.com \\ OCTOBER 2017

47
http://www.Orthotown.com http://www.orthotown.com/onlinece http://www.Orthotown.com http://www.orthotown.com
Table of Contents for the Digital Edition of Orthotown October 2017
