AO ASIF Principles of Operative Treatment
of Craniomaxillofacial Trauma and Reconstruction
Registration Form

May 17 - 18, 2003
Seattle, Washington

Course Name:


Registration is required in advance, as seating is limited. Immediate response is encouraged.

Registration fee is $275.00 for attending surgeons and $95.00 for residents (with letter from Program Chairman). Fee includes all course and lab materials, continental breakfasts, lunches and refreshments. Refunds (less $25.00 administration fee) will be issued if written cancellation notice is received by May 8, 2003.

Applications will not be accepted unless the Course tuition fees are included with registration form and Pre-Course Questionnaire.

(Please print or type clearly)

You have the option to print this form, complete and return with payment to:

AONA Continuing Medical Education
Re: Seattle Craniomaxillofacial Course for Surgeons
1690 Russell Road
Paoli, PA 19301
Tel: (800) 769-1391 or (610)695-2459
Fax: (610) 695-2420

or you can complete this form and submit online using a credit card. Please select one of the payment methods below:

Enclosed is my check payable to:
"AO ASIF CONTINUING MEDICAL EDUCATION"

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(American Express not accepted)
Exp. Date: Card Number:

Signature (All credit card orders must be signed, if mailing or faxing this form):


Name:


Degree(s):

PGY:

Home Address:
City:
State:
 Zip:

Business Phone:
 Home Phone:
 Fax Number:

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Social Security No. (For documentation purposes only):

Do you have any special needs:

PRE-COURSE QUESTIONNAIRE

MUST BE COMPLETED FOR REGISTRATION FORM TO BE PROCESSED

1. How many years in practice? Percentage of practice devoted to Craniomaxillofacial Surgery:%
Private Practice? Yes NO If no, please specify:

2. PGY
Are you considering Craniomaxillofacial trauma/reconstruction as a career choice?Yes No

3. Specialty Training? (check one)
Oral and Maxillofacial Surgery
Otolaryngology-Head and Neck Surgery
Plastic/Reconstructive Surgery
Other

4. Hospital/University Affiliation:

5. As a participant, please check what you expect to learn from the Course:
Principles of stable internal fixation
Biological and Mechanical aspects of fracture healing
Stabilization techniques
Perioperative management of craniofacial trauma patients
Management of complications and failures
Reconstruction techniques
Other
Please explain:

Until official written confirmation is received, please do not consider yourself registered for this Course.

Please press this button
to submit your registration form:

Thank you.

Course Information