Fields indicated in red are required.

First Name

M.I.

Last Name

Primary Degree

MD    DMD     DDS   Other

Specialty

Plastic and Reconstructive Surgery 
Oral and Maxillofacial Surgery 
Otolaryngology—Head & Neck Surgery
Neurosurgery 
Other

Subspecialty

Affiliation

Address

Address

City

State

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ZIP/Postal Code

Country

United States Other     Other

Phone

ext.

Fax

Email

(Primary method of delivery of confirmation)

Medical Education #

Medical Education (ME) # assigned by the AMA or last 4 digits of social security number (for CME credit)

ImproMED intends to fully comply with the legal requirements of the Americans with Disabilities Act. Please check if you have any special assistance needs or dietary restrictions.

I have the following need(s):

Includes scientific sessions, continental breakfast, break refreshments, lunch, course handouts, and Continuing Medical Education (CME) credit certificate(s).

$425 Attending Physicians/Surgeons

$75 Residents and Allied Health Personnel
      (Limited seating; tuition is nonrefundable.)

You will receive a registration confirmation and credit card receipt via email once your registration information and tuition has been processed.

I hereby authorize ImproMED to charge the credit card listed below for this course. I understand that payment for the amount charged is solely the responsibility of the person or company whose name is on the card and attest that I am authorized to use this card for this purchase.

MC Visa American Express Discover

Month (mm)  Year (yyyy)

Credit Card Billing Address and Email are the same as above

Address

Address

City

State

Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WV WA WI WY          or Province

ZIP/Postal Code

Country

United States Other     Other

Email

Your tuition, less a $75 processing fee, will be refunded if cancellation notification is received by ImproMED two (2) weeks prior to the symposium. Cancellations made after this date, will forfeit the entire registration fee, unless a justifiable emergency is documented.

ImproMED reserves the right to cancel this activity due to national/global occurrences outside of our control. Should cancellation occur, all parties involved would be notified as early as possible.