Virtual Clinic Registration


Clinic registration does not replace the Support Book or the Virtual Clinic Home registration of your parents. It is our intention that parents should have regular access to support materials for use with their children (Orton Annals of Dyslexia, C. McGuinness, et al, 1996)..


Required fields are marked with an asterisk (*).
*Clinic name: 
*Contact First Name:
*Contact Last Name:
*Your Email Address:
*Confirm Your Email Address:
*Address:
*City:
*State:
 - Province/County if not in list
*Postal Code:
*Country:
*Phone Number:

Special Instructions or Notes:

Payment Information
The cost of the Virtual Clinic is $85.
Mastercard, Visa, Discover, and American Express are accepted.

     
Select a payment option:  
Credit Card Number
(no spaces or dashes):
Security Code
(from the back of the credit card):
Credit Card Expiration: Month: Year:
Select a Username and Password
Your username will be supplied for you in your confirmation email.



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