November 2019 Lumbar Endoscopic Spinal Decompression Review Course

NOVEMBER 2019 LUMBAR ENDOSCOPIC SPINAL DECOMPRESSION REVIEW COURSE 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:

Medical Degree: *

MD DO PhD

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Primary Specialty Certification: *

Anesthesiology Neurology Physiatry

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Pain Medicine Subspecialty Certification *

American Board of Anesthesiology American Board of Interventional Pain Physicians Fellow of Interventional Pain Practice American Board of Pain Medicine Competency in Regenerative Medicine Competency in Interventional Pain Management

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Fellowship Training *

Pain Medicine Spine Surgery Sports Medicine

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Years in Interventional Pain Management practice: *

0 1-5 6-10 More than 10

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Number of Years Experience in Lumbar Spinal Endoscopic Decompression *

0 1-5 6-10 More than 10

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Please indicate the total number of procedures during the past year for each of the procedures below.

Percutaneous disc decompression (Disc FX/Perculine) *

Lumbar Endoscopic Medial Branch transection (rhizotomy) *

Cervical Endoscopic Facet Debridement *

SI Joint Endoscopic Denervation *

Transforaminal Endoscopic Discectomy *

Tranforaminal Endoscopic Foraminoplasty *

Interlaminar Endoscopic Discectomy *

Interlaminar Endoscopic Lateral Recess Decompression *

Exforaminal Transforaminal Endoscopic Discectomy *

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Please indicate the number of Lumbar Endoscopic Spinal Decompression courses you have attended with ASIPP and at which level; two are required for the advanced level of this course:

Basic *

0 1 2 3

Intermediate *

0 1 2 3

Advanced *

0 1 2 3

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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

* To participate in the Basic Level of the cadaver workshop you must have previously performed discograms and transforaminal epidural injections.

* To participate in the Intermediate Level of the cadaver workshop you must have previously performed discograms and transforaminal epidural injections AND attended at least 2 ASIPP courses, including the basic level of the ASIPP® Lumbar Endoscopic Spinal Decompression, or have performed at least 5 cases.

* To participate at the Advanced Cadaver Workshop level you must have attended 2 previous ASIPP® Lumbar Endoscopic Spinal Decompression courses (Basic and Intermediate) and performed cases, or performed 10 - 20 cases.

*Please Submit 1-2 Cases that you are considering treating with endoscopic techniques. Include MRI Images (saggital/axial) and AP/lateral radiographs and brief subjective complaint/physician exam. Faculty will present these cases during the panel discussion and discuss potential treatments considering your level of experience.

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Course Level *

Basic Intermediate

Payment Information

*

Cadaver Workshop and Review Course -- Member $ 4,650.00

Cadaver Workshop and Review Course --Non-Member $ 4,950.00

Review Course Only -- member $ 1,000.00

Review Course Only -- Non-Member $ 1,100.00

Total $ 0.00

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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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