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" The Voice Of Interventional Pain Management "

ONLINE REGISTRATION
American Society of Interventional Pain Physicians
Vertebroplasty, Kyphoplasty, Sacroplasty Interventional Techniques Review Course
Comprehensive Interventional Cadaver Workshop
Feb. 8-10, 2008

Memphis Marriott Downtown • 250 North Main Street • Memphis, Tennessee 38103 USA
Phone: 1-901-527-7300 • Toll Free: 1-888-557-8740 • Fax 1-901-526-1561

Attendee Information:
First Name:	Last Name:
Title:	Organization:
Address:	City:
State:	Zip:
Phone:	Fax:
E-mail:	Date of Birth:
		Male Female

IMPORTANT: Please answer the following questions.
Primary Specialty: Anesthesiology Physiatry Neurology Other
Pain Management Subspecialty:
	American Board of Anesthesiology
	American Board of Pain Medicine
	American Board of Interventional Pain Physicians
	Fellow of Interventional Pain Practice (FIPP)
Specialty Designation:
09 - Interventional Pain Management 72 - Pain Medicine Other
Percentage of Interventional Pain Management Practice: (Choose percentage below)
0% \| 1-25% \| 26-50% \| 51-75% \| 76% or more
Number of years in Interventional Pain Management practice:
0 \| 5 \| 6-10 \| 10 or more
Rate your comfort level with Interventional Pain Management
1 \| 2 \| 3 \| 4 \| 5

To be assigned you are required to fill out the survey below:
Total # of Procedures you have performed in the last year.	Location
	ASC	HOPD	Office
Lumbar Vertebroplasty:
Thoracic Vertebroplasty:
Lumbar Kyphoplasty:
Thoracic Kyphoplasty:
Sacroplasty:
Workshop Registration Information:
American Society of Interventional Pain Physicians:		Registration Dates
Registration Fee for Courses:		Payment on or before 01/25/08	Payment after 01/25/08
Interventional Techniques Review: Course & Cadaver Workshop Vertebroplasty/Kyphoplasty/Sacroplasty (Member Pricing)		$2,200	$2,500
Interventional Techniques Review: Course & Cadaver Workshop Vertebroplasty/Kyphoplasty/Sacroplasty (Non-Member Pricing)		$2,500	$2,700
Fellow Member (Click here only if you are a Fellow member to receive discount. Your membership status will be reviewed upon receipt of form)		50% Discount	50% Discount
Payment Method
I will mail a check to ASIPP
Mastercard \| Visa \| Discover \| American Express
Card Number:		Exp. Date:
Cardholder's Name:

	Cancellation Policy: ASIPP reserves the right to cancel this workshop 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. Registrants who are not accepted into this workshop will receive notice by mail with their returned check. ASIPP requires a 45-day notice for registrant’s cancellation. Cancellations must be submitted in writing and received by January 1, 2008. An administrative fee of $200.00 will be assessed. Cancellations after January 1, 2008 but prior to January 24, 2008 will forfeit 50% of their registration fee. No cancellations accepted after January 24, 2008. Refunds will be sent after the conclusion of the meeting. Registration Information: Approximately 70 participants will be allowed in the workshop and/or Board preparation. Please complete the enclosed registration form and return to ASIPP with payment (your application will not be processed until payment is received). ASIPP reserves the right to cancel this workshop seminar upon reasonable notice and will assume no financial obligation to registrants for cancellation of the course 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. Registrants who are not accepted into this seminar will receive notice by mail with their returned check.