Regenerative Medicine Review Course June 10-11 2023

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:

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Medical Degree:*

MDDOPhD

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Primary Specialty Certification:*

AnesthesiologyNeurologyPhysiatry

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Pain Medicine Subspecialty Certification*

American Board of AnesthesiologyAmerican Board of Interventional Pain PhysiciansFellow of Interventional Pain PracticeAmerican Board of Pain MedicineCompetency in Regenerative MedicineCompetency in Interventional Pain Management

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Fellowship Training*

Pain MedicineSpine SurgerySports Medicine

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What is your practice location

ASCHOPDOffice-setting

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Years in Interventional Pain Management practice:*

01-56-10More than 10

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Number of Years Experience in Regenerative Medicine:*

01-56-10More than 10

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

Soft Tissue and Ligament Injections*

Shoulder Injections*

Elbow Injections*

Wrist Injections*

Hip Injections*

Knee Injections*

Ankle Injections*

Sacroiliac Joint Injections*

Caudal Epidural Injections*

Lumbar Interlaminar Epidural Injections*

Lumbar/Sacral Transforaminal Epidural Injections*

Lumbar/Sacral Facet Joint Nerve Blocks*

Lumbar Facet Joint Intraarticular Injections*

Lumbar Discography*

Pudendal Nerve Blocks*

Ultrasound Guided Injections*

* If registering as a Resident or Fellow, please list below the name of fellowship program, university or hospital and fax or e-mail a letter from the program director verifying your status. Your application for registration cannot be processed and you will not receive the discount until ASIPP receives this letter. Fax the letter to 270-554-5394 or e-mail to crogers@asipp.org

Payment Information

*

Cadaver Workshop - Member$3,000.00

Cadaver Workshop - Non-Member$3,200.00

Cadaver Workshop and Recorded 2-day Review Course- Resident/Fellow$1,500.00

Proof of residency or fellowship must be provided to Cindy Rogers at crogers@asipp.org prior to your acceptance into the course at this discounted price.

Virtual Review Course Recording Add-on$200.00

No CMEs

Total $0.00

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CANCELLATION POLICY FOR LAB:

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 May 25, 2023 but prior to May 25, 2023 will forfeit 50% of their registration fee. No refunds can be made after May 25, 2023.

CANCELLATION POLICY FOR VIRTUAL REVIEW:

No refunds for recorded review course.

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