Implementing Medication Assisted Treatment (MAT) into your practice Registration Form Heading link Copy link Name * Required First Last Email * Required Profession * RequiredPhysicianPhysician AssistantNurse PractitionerPharmacistNurseIf you selected "other" for profession, please specify below Dietary restrictions * Required Vegetarian Vegan Gluten-free None Other If you selected "other" for dietary restrictions, please specify below Will you be attending (check all that apply): * Required Select All Friday, November 8, 2019 Saturday, November 9, 2019 Type of practice * RequiredFamily MedicinePediatricsInternal MedicineEmergency MedicineOB/GYNOtherIf you selected "other" for type of practice, please specify below Do you provide prenatal care? * Required Yes No Do you have your DEA-X waiver to prescribe buprenorphine? * Required Yes No Do you plan to obtain your DEA-X waiver to prescribe buprenorphine? * Required Yes No Have you prescribed buprenorphine/naloxone or buprenorphine for Opioid Use Disorder? * Required Yes No Name of practice * Required Zip code of practice * Required EmailThis field is for validation purposes and should be left unchanged.