Registration Form for
AO ASIF Advanced Controversies in Fracture Care Course

March 22 - 27, 2003
The Broadmoor Resort
Colorado Springs, Colorado

(Please type or print clearly)

Course Name:

Name:

Degree(s):

Social Security Number (For documentation purposes only):

Guest's Name (if any):

Address:

Check one: Home Office

City:
 State:
 Zip:

Phone (Office):
 Phone (Home):
 Fax Number:
E-mail address:

Hospital affiliation:

PGY: I II III IV V Fellow

Have you ever attended an AO ASIF Course? Yes No
If yes, when and where?:

Tuition Enclosed:
Advanced Controversies in Fracture Care $1,475.00
$1,095.00

*Letter from department head must accompany registration form and payment to qualify for resident tuition.

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

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

AONA Continuing Medical Education
Re: Advanced Controversies in Fracture Care Course
1690 Russell Road
Paoli, PA 19301
Tel: (800) 769-1391/(610) 695-2459
Fax: (610) 695-2420

or you can complete and submit the form online.

Enclosed is my check for $ made payable to: AO ASIF Continuing Medical Education

Charge my credit card:

(American Express not accepted)

Exp.Date: Card Number:
Signature (if mailing or faxing form):

Do you have any special needs:


PRE-COURSE QUESTIONNAIRE-MUST BE COMPLETED FOR REGISTRATION FORMS TO BE PROCESSED

1. Are you considering trauma as a career choice in orthopaedics? Yes No

2. Percentage of practice dedicated to trauma surgery? %

3. As a participant, please check off what you expect to learn from the Course.

Principles of Fracture Management Basic knowledge of operative treatment
Trauma principles and techniques Internal and external fixation
Preoperative planning methods Reduction and stabilization techniques
AO concepts and procedures Other

Please do not consider yourself registered for this course until written confirmation is received.

Please press this button to submit your registration form:

Thank you.

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