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" The Voice Of Interventional Pain Management "

ONLINE REGISTRATION
Comprehensive Review Course and Cadaver Workshop
(Basic, Intermediate, and ABIPP Part II Preparation)
October 9-11, 2009

The Peabody Memphis :: 149 Union Ave
Memphis, TN 38103 :: (901) 529-4164

Attendee Information:
First Name:	Middle Initial:
Last Name:	Title:
Organization:	Address:
City:	State:
Zip:	Country:
Phone:	Fax:
Cell:	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 ( ABIPP)
	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 (Minimum (1) to Maximum (5))
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

Caudal Epidural:

Sphenopalatine Blocks:

Stellate Ganglion Blocks:

Thoracic Sympathetic Blocks:

Lumbar Discography:

Sacral Transforaminal Epidural:

Lumbar Sympathetic Blocks:

Caudal Epidural:

Lumbar Facet Joint Blocks:

Thoracic Interlaminar Epidural:

Cervical Interlaminar Epidural:

Cervical Facet Joint Blocks:

Cervical Radiofrequency:

Thoracic Joint Blocks:

Thoracic Radiofrequency:

Lumbar Radiofrequency:

Lumbar Transforaminal Epidural:

Hypogastric Plexus Blocks

Sacroiliac Joint Injections

Pyriformis Block

Percutaneous Adhesiolysis:

American Society of Interventional Pain Physicians:

Registration Dates

Registration Fee for Courses:

Payment on or before 09/14/09

Payment after 09/14/09

Interventional Techniques Review Course and Cadaver Workshop
(Member Fee)

$2,200

$2,500

Interventional Techniques Review Course and Cadaver Workshop
(Non-Member Fee)

$2,500

$2,800

Interventional Techniques Review Course
(Member Fee)

$400

$500

Interventional Techniques Review Course
(Non-Member Fee)

$500

$600

Cadaver Workshop
(Member Fee)

$2,000

$2,300

Cadaver Workshop
(Non-Member Fee)

$2,300

$2,500

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

Payment Method:

Mastercard | Visa | Discover | American Express

Card Number:

Exp. Date:

Security Code:

Cardholder's Name:

Cancellation Policy:

ASIPP requires a 30-day notice for registrant’s cancellation. Cancellations must be submitted in writing and received by September 14, 2009. An administrative fee of $200 will be assessed. Cancellations after September 14, 2009, but prior to September 25, 2009 will forfeit 50% of their registration fee. No cancellations accepted after September 25, 2009. Refunds will be sent after the conclusion of the meeting.

Registration Information:

Approximately 70 participants will be allowed in the Review Course and/or Workshop. Please complete the registration form and submit 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. In this event, 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 and reimbursement with their returned check.