PNS Interventional Techniques in IPM Cadaver Workshop June 9-10, 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:

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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Years in Interventional Pain Management practice:*

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.

Caudal Epidural Injections*

Lumbar Interlaminar Epidural Injections*

Lumbar/Sacral Facet Joint Nerve Blocks*

Lumbar Facet Joint Interlaminar Injections*

Lumbar Facet Radiofrequency*

Lumbar/Sacral Transforaminal Epidural Injections*

Percutaneous Adhesiolysis*

Sacroiliac Joint Injections*

Lumbar Discography*

Percutaneous Lumbar Discectomy*

Cervical Interlaminar Epidural Injections*

Cervical Facet Joint Nerve Blocks*

Cervical Facet Joint Intraarticular Injections*

Cervical Facet Radiofrequency*

Cervical Discography*

Facet Joint Nerve Blocks*

Thoracic Interlaminar Epidural Injections*

Thoracic Facet Radiofrequency*

Thoracic Discography*

Stellate Ganglion Blocks*

Celiac Plexus Blocks*

Lumbar Sympathetic Blocks*

Hypogastric Plexus Blocks*

Trigeminal Nerve Blocks*

If Registering for Cadaver Workshop:

Cadaver Workshop Level*

BasicIntermediateAdvanced

Basic*

Intermediate*

Advanced*

Payment Information

The cadaver workshop has limited spaces - early registration is encouraged.

*

Cadaver Workshop Only - Member $3,000.00

Cadaver Workshop Only - Non-Member$3,200.00

Recorded 2-day Comprehensive Review Course in PNS$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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