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Please complete all fields marked with an asterisk, as these are required for program registration.

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Last Name *

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Title

Primary Practice Name *

Address 1 *

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Address 2

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I attest that my job responsibilities are directly involved in Patient Care, as that term is defined by Dompe.

Yes

Branded Program Attestation: I understand that I am attending a Dompe-sponsored Oxervate speaker program regarding the diagnosis of NK and its treatment of Oxervate. I attest that I have an educational need to receive the content of, and participate in, this speaker program based on my job responsibilities (including, for non-prescriber staff, my role-based need for the content), the specialty and patient population of my practice, and my level of familiarity with NK. To the best of my knowledge, I have not previously attended a Dompe program on the same or substantially similar content.

Yes

Disease State Program Attestation: I understand that I am attending a Dompe-sponsored speaker program focused on the NK disease state, including its pathophysiology and diagnosis. I attest that I have an educational need to receive the content of, and participate in, this speaker program based on my job responsibilities (including, for non-prescriber staff, my role-based need for the content), the specialty and patient population of my practice, and my level of familiarity with NK. To the best of my knowledge, I have not previously attended a Dompe program on the same or substantially similar content.

Yes

Program Details

Program #: 30524

Date: 09/10/2026

Time: 12:00 PM

Speaker: Jeff Banas

Rep Name: Eric Furcht

Rep Phone: 612-991-3107

Venue

Venue Name: Eyecare Professionals

Address 1: 113 3rd Avenue

Address 2:

City: Mandan

State: ND

Zip: 58554

Dompe U.S. Inc. Speaker Programs are intended for U.S. accredited Health Care Professionals only. Attendance is not open to the public.
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