Course Sign-Up:

• Medical & Dental Spanish

• International Medicine

• Art of Compassionate Medicine

• MedSpanOnline

Invoice Request Page



Instructions:

1) Please complete the short form below.

2) Upon receipt of this form, we will create and send
an invoice to you.

3) You can pay this invoice using a credit or debit card
via PayPal. You do not need to be a member of PayPal.

4) Instructions for completing the transaction will come
to you with the invoice

Thank you. We look forward to your participation.

Personal Information:
First Name:
Middle Initial:
Last Name:
Email Address:
Telephone Number:
Dates of Participation:

Choose a Course:
 Check one box below

Medical & Dental Spanish
International Medicine
Art of Compassionate Medicine
MedSpanOnline

(If you check the MedSpanOnline box, leave the
remainder of the form blank, and click the Submit
button below.)

Choose Payment Method:
 Check one box below

Full Payment

(check the full payment box if you are within 12 weeks
of the start of your elective)

80% Final Payment

(check the 80% final payment box if you are within 12
weeks of the start of your elective and previously have
made the 20% deposit)

20% Deposit

(check the 20% deposit box if you are more than 12
weeks from the start of your elective)

Choose Elective Duration:
 Check one box below

1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
Other

(If you check the "Other" box, please complete the special needs section below.)

Transportation Option:
 I want roundtrip, in-country transportation ($70)

Message / Questions

/ Special Needs:



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