Crossroads Brochure - UT Southwestern Medical Center at Dallas

OPHTHALMOLOGY AT THE CROSSROADS 2013:A CHANGING PERSPECTIVER E G I S T R A T I O NF O R MSaturday, December 14, 2013#RP1312ANameAddressCity State Zip CodeLast Four Digits of SS#Business PhoneDegree❏ UT Southwestern AlumniFaxSpecialtyEmail Address:INDICATE CREDIT DESIRED: o AMA o GeneralPlease indicate which Lunch Discussion Group you would like to join:o Electronic Health Recordso Train Wreck Ethics Continuedand Other Ethical Challenges(Additional 1 hour of Ethics Credit offered)o Coding Questionso Zen LunchREGISTRATION FEE: ____ $100 Physicians____ $90 UT Southwestern Alumni____ $75 AlumnEye Association Members____ $35 ResidentsCHECKS ONLY, PLEASE!Make check payable to:UT Southwestern Department of OphthalmologyMail completed registration form and check to:UT Southwestern Medical CenterOphthalmology Education Office5323 Harry Hines BoulevardDallas, Texas 75390-9057CANCELLATION POLICYUT Southwestern/Department of Ophthalmology reserves the right to limitregistration and cancel courses, no less than one week prior to the course,should circumstances make this necessary.REFUND POLICYA handling fee of $25 will be deducted from cancellation refunds. Refund requestsmust be received by mail or fax prior to December 6, 2013. No refunds will bemade thereafter.ADA STATEMENT ❏ Please check this box if you require assistance because of a disability to make thisprogram accessible to you. Someone from our office will be in touch with you.