November 2019 Regenerative Medicine Review Course

REGENERATIVE MEDICINE REVIEW COURSE AND CADAVER WORKSHOP REGISTRATION FORM

DATE
November 1-3, 2019

VENUE
Hilton Memphis
939 Ridge Lake Blvd. Memphis, TN 38120 | (901) 684-6664 | Hotel Reservation

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

**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:

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MDDOPhDOther

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AnesthesiologyNeurologyPhysiatryOther

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

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Pain MedicineSpine SurgerySports MedicineOther

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ASCHOPDOffice-setting

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01-56-10More than 10

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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*

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Please indicate how many Regenerative Medicine courses you have previously taken with ASIPP and at which level:

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Please indicate if you have previously taken a course with any other organization and at which level:

Course Name

Level

Times Attended

Cadaver Workshop Levels

* 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

BasicIntermediateAdvanced

Payment Information

Cadaver Workshop and Review Course -- Member$3,500.00

Cadaver Workshop and Review Course --Non-Member$3,800.00

Cadaver Workshop and Review Course Fellow/Resident*$1,900.00

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. Cancellations must be submitted in writing by October 1, 2019. Cancellations after October 1, 2019 but prior to October 17, 2019 will forfeit 50% of their registration fee. No refunds can be made after October 17, 2019.

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