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Lecoq
 Practice Development

 

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You may use this form to register for any of our courses or programs. 
Or you can ask us to contact you for information about any of our offerings.

To protect your security, we do not collect financial information online.
We will call you to handle credit card or other payment arrangements. 

Your Full Name:      Title:

Course/Date        

Practice Name    

Address:  (If international, type your complete address in this box)

                          

City:                         State     ZIP:

Office Phone:         Email

                           Who plans to attend?   Please list all names and titles:
      Doctor(s):    

    Assistants:     

                           Contact Information - For information, payment arrangements:

    Best Phone #:     Best day to reach you:    Best time:

    I would like to receive your occasional e-mails and practice building gifts. 
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Lecoq Practice Development
14420 Iroquois Rd. Apple Valley, CA 92307

CONTACT US BY PHONE:     760-686-4648
To Reach Thomas Lecoq:  idealvt@verizon.net
To Reach Amee Lecoq: idealvt1@verizon.net 
For Therapist Training, Lyna Dyson:  visionhlp@juno.com
FAX  760-262-3172
 

Copyright 2009 Lecoq Practice Development
Last modified: 05/12/17