MGM Grand Detroit WSU School Of Medicine – Scott Hall

Course RegistrationAdvanced Regional Anesthesia 2010:Invasive Pain Management Techniques andRegional Anesthesia Hands-On WorkshopMay 14 - 16, 2010Note: Program attendance will be limited to 90 participants, so early registration isrecommended. Please complete and mail or fax to arrive by April 16, 2010.First Name:_____________________________Degree Specialty:_______________________Last Name:_ ______________________________M.D./D.O./Other __________________________Mailing Address:___________________________________________________________________Phone___________________________________________________ Fax_ _____________________E-mail_________________________________Last four digits of SS#:______________________Fees: Received by April 16, 2010 Received after April 16, 2010Practicing Physicians $450 $500 ____________Residents $250 $300 ____________(Requires letter from Program Director)Other Healthcare Professionals $300 $350 ____________Advanced Workshop* $150 $150 ____________*Only available with full course registrationCourse syllabi only, not attending conference $50 $50 ____________Note: Workshops will be filled on a first-come, first served basisTotal$___________Please check all that apply______ Friday evening complimentary dinner program (CME credit)______ Vegetarian Meals______ Please check here if you have a disability and may require accommodation to fully participate.You will be contacted by Wayne State University.Payment Method (Please check one)_____ Check enclosed (payable to Anesthesia Services, PC)_____ Credit Card (Visa or MasterCard)Card Number ______________________________ Exp. Date __________Refund Policy: Cancellations must be made in writing and received on or beforeApril 30, 2010, for a refund (less a $50 processing fee). No refunds after April 30, 2010.Mail to:Anesthesia Services, PCPO Box 1009Jackson, MI 49204Phone: (800) 242-1131 ext. 4382Fax (517) 787-0529E-mail tawna.brautigam@anesthesiallc.combooklet layout 8 pg wider.indd 79/29/2009 9:54:07 AM

Anesthesia Services, P.C.255 West MichiganP.O. Box 1009Jackson, Michigan 49204Advanced Regional Anesthesia 2010Invasive Pain Management Techniques and Regional AnesthesiaHands-On WorkshopMay 14 - 16, 2010booklet layout 8 pg wider.indd 89/29/2009 9:54:07 AM