July 2021 Lumbar Endoscopic Spinal Decompression Review Course

Cadaver Workshop Venue
Medical Education and Research Institute
44 South Cleveland, Memphis, TN 38104 |(901) 722-8001| (800) 360-6374

Room Block for Cadaver Workshop:
Guest House at Graceland
3600 Elvis Presley Blvd.
Memphis, TN 38116

**This course is open to physicians only*

Personal Information:

First Name: *

Middle Initial:

Last Name: *

Organization:

Address: *

City: *

State: *

Zip: *

Phone: *

Cell:

Fax:

E-mail: *

Please answer all of the following questions:

Medical Degree: *

MD DO PhD

----------------------------------------------------------------------

Primary Specialty Certification: *

Anesthesiology Neurology Physiatry

----------------------------------------------------------------------

Pain Medicine Subspecialty Certification *

American Board of Anesthesiology American Board of Interventional Pain Physicians Fellow of Interventional Pain Practice American Board of Pain Medicine Competency in Regenerative Medicine Competency in Interventional Pain Management

----------------------------------------------------------------------

Fellowship Training *

Pain Medicine Spine Surgery Sports Medicine

----------------------------------------------------------------------

Years in Interventional Pain Management practice: *

0 1-5 6-10 More than 10

----------------------------------------------------------------------

Number of Years Experience in Lumbar Spinal Endoscopic Decompression *

0 1-5 6-10 More than 10

----------------------------------------------------------------------

Please indicate the total number of procedures during the past year for each of the procedures below.

Percutaneous disc decompression (Disc FX/Perculine) *

Lumbar Endoscopic Medial Branch transection (rhizotomy) *

Cervical Endoscopic Facet Debridement *

SI Joint Endoscopic Denervation *

Transforaminal Endoscopic Discectomy *

Tranforaminal Endoscopic Foraminoplasty *

Interlaminar Endoscopic Discectomy *

Interlaminar Endoscopic Lateral Recess Decompression *

Exforaminal Transforaminal Endoscopic Discectomy *

Payment Information

Cadaver lab has limited spaces however the review course is unlimited. Early registration is encouraged.

*

Cadaver Workshop and Review Course -- Member $ 4,650.00

Cadaver Workshop and Review Course --Non-Member $ 4,950.00

Virtual Review Course Only - Member $ 1,000.00

Virtual Review Course Only - Non-Member $ 1,100.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

CANCELLATION POLICY:

ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded, however, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. ASIPP requires a 30-day notice of cancellation for cadaver workshops. Cancellations for cadaver workshop after July 1, 2021 but prior to July 17, 2021 will forfeit 50% of their registration fee. No refunds can be made after July 17, 2021.

Enter the message as it's shown *