Midwest Society of Colon and Rectal Surgeons - Creighton ...

COURSE DIRECTORS
Jennifer S. Beaty, MD, FACS
Assistant Clinical Professor
Department of Surgery
Section of Colon and Rectal Surgery
Creighton University School of Medicine
Omaha, Nebraska
Charles A. Ternent, MD, FACS, FASCRS
Assistant Clinical Professor
Department of Surgery
Section of Colon and Rectal Surgery
Creighton University School of Medicine
Omaha, Nebraska
FACULTY
Jeffrey B. Albright, MD, FACS
Surgeon, Colorectal and General Surgery
Birmingham Surgical PC
Birmingham, Alabama
230091-811620
5 EASY
Y
Please watch your
email for conference
confirmation!
WAYS
TO REGISTER
1 ON-LINE
Register on-line at:
http://cme.creighton.edu
2 FAX
FAX: 1-402-280-5180
3 MAIL
Mail the registration form to:
Creighton University School of Medicine
Continuing Medical Education Division,
601 N. 30th St., Suite 2130, Omaha, NE 68131-2100.
Make check payable to Creighton University.
4 PHONE
Our staff will be happy to register you by phone.
Just call Monday - Friday, 8:00 a.m. - 4:30 p.m.
1-800-548-CMED (Continental USA) or 1-402-280-5659
5 ON-SITE
We would be happy to have you register at the
conference. However, if your registration is not received
at least 5 working days prior to the conference we
cannot guarantee you seating or conference materials.
REGISTER TODAY!
Please forward to a colleague if unable to attend
FACULTY
Richard M. Devine, MD
Professor
Division of Colon and Rectal Surgery
Mayo Clinic
Rochester, Minnesota
Muneera R. Kapadia, MD
Clinical Assistant Professor
Department of Surgery
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Mark Katory, MBCHB, MD, FRCS
Consultant Laparoscopic Colorectal Surgeon
Department of Colorectal Surgery
Queen Elizabeth Hospital
Gateshead, United Kingdom
Jennifer L. Kemp, MD
Chairman, Rose Radiology
Diversified Radiology of Colorado, PC
Denver, Colorado
REGISTRATION
20TH Annual Winter Meeting:
Midwest Society of Colon and Rectal Surgeons
March 9 –11, 2011
YES! Please register me.
Emilio Morpurgo, MD
Chairman, Department of Surgery
Center for Minimally Invasive and Robotic Surgery
Hospital of Camposampiero
Padova, Italy
William J. Peche, MD, FACS
Assistant Professor of Surgery
Department of Colon and Rectal Surgery
University of Utah
Salt Lake City, Utah
Bartley Pickron, MD
Minimally Invasive Colon and Rectal Surgery Fellowship
University of Texas Medical School at Houston
Colorectal Surgical Associates
Houston, Texas
Leslie A. Roth, MD
Surgeon, Colorectal and General Surgery
University Surgical Associates
Assistant Professor of Surgery
Warren Alpert Medical School of Brown University
Providence, Rhode Island
FEE: Physicians @ $195.00 Fellows @ $90.00
(NOTE: To ensure lodging, reservations must be made with The Crestwood by December 20, 2010.)
(PLEASE TYPE OR PRINT)
I plan to attend the Wednesday evening Pizza Party
Yes _____ # of People attending (including self)
No
S153
REGISTRATION WILL BE COMPLETE AND CONFIRMATION SENT UPON RECEIPT OF REGISTRATION FEE.
What specific information would you like to receive at the conference?
________________________________________________________________________________________________________
Do you require any special accommodations (dietary, mobility, hearing, etc.) for the meeting? Yes No
If yes, please explain: ____________________________________________________________________________________
Are you an alumnus of Creighton University? Yes No
If yes, from which school did you graduate? ________________________________________________________________
E-mail (required for confirmation) ___________________________________________________________________________
Name __________________________________________________________________________________________________
First MI Last (MD, NP, PA, RN, etc.)
Specialty/Department ___________________________________________ License Number___________________________
(non-physician)
Address ________________________________________________________________________________________________
City, State ________________________________________________________________Zip __________________________
Phone: Office (_________) ______________________________ Home (_________) ________________________________
FAX: (________)__________________ Social Security Number X X X – X X – ___ ___ ___ ___ (Last 4 Digits Only)
Please charge my for $ _____________________
___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___ ___________________
Account Number Exp. Date
__________________________________________________________________
Name as it appears on card (if different from above) - Please Print
__________________________________________________________________
Signature
I have enclosed a check made payable to Creighton University for this conference only in the amount of $_____________
If you have already registered by phone and paid by credit card, it is not necessary to return this form.
THIS FORM MAY BE DUPLICATED
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