Verification of Participation & Certificate Request 29 th Annual Congress Orlando, Florida November 12 15, 2015

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1 Complete this form in its entirety to claim the credits commensurate with your participation at the ACP s 29 th Annual Congress. You can only claim credit for one session if it runs concurrently with others. ACP staff will calculate your credit total and fill in the hours for which you participated. Note that the maximum credits awarded for participation at the 29 th Annual Congress are as follows: 30 AMA PRA Category 1 Credits TM ; 30 AOA Category 2-A credits; 30 SVU-CMEs; 30.5 nursing contact hours. Note that all new or reprint certificate requests received after Monday, November 30, 2015 will be considered on a case-by-case basis and are subject to an administrative processing fee of $ Please submit the completed form to the ACP headquarters by (education@acpmail.org) or fax ( ). PARTICIPANT INFORMATION Full Name (including degree/designation) License # (nurses ONLY) Address Telephone RTIFICATE REQUEST TYPE & PARTICIPATION ATTESTATION Check all that apply: CME Certificate Request (MDs and DOs only) SVU-CME Certificate Request Nursing Certificate Request Certificate of Attendance Request Note that AMA PRA Category 1 Credit TM should be claimed in increments of 0.25 hours commensurate with the extent of the learner s participation in the activity. For Nursing, learners must participate in an entire session in order to claim credit; credit for partial participation cannot be issued. I certify that I am claiming only the credit commensurate with the extent of my participation in this activity. Signature: Date:

2 THURSDAY, NOVEMBER 12, :00 AM 5:00 PM Track A Basic Phlebology 8:00 AM 5:00 PM Track B Basic Ultrasound 8:00 AM 5:00 PM Track C Practice Management 8:00 AM 5:00 PM Track D Advanced Phlebology FRIDAY, NOVEMBER 13, :00 AM 8:00 AM Current Sclerotherapy Practices 7:00 AM 8:00 AM Pelvic Venous Disorders 7:00 AM 8:00 AM Venous Wound Management Beyond Compression 7:00 AM 8:00 AM Compression Hands-On Workshop 7:00 AM 8:00 AM Non-Thermal Techniques for Saphenous Vein Treatment Hands-On Workshop 7:00 AM 8:00 AM Superficial Venous Imaging Hands-On Workshop 8:00 AM 8:50 AM Phlebology Year In Review 8:50 AM 10:00 AM Abstract Award Presentations :00 AM 12:00 PM Nursing Symposium Sclerotherapy 9:00 AM 12:00 PM The Ultrasound Room: From Basic and Beyond I 10:30 AM 12:00 PM Abstract Session :00 PM 3:00 PM Nursing Symposium Advanced Practice 1:00 PM 3:00 PM The Ultrasound Room: From Basic and Beyond II 1:00 PM 3:00 PM Lymphedema: Basic Biology

3 FRIDAY, NOVEMBER 13, 2015 (Continued) 1:00 PM 3:00 PM Modern Saphenous Vein Treatment 1:00 PM 3:00 PM Treatment of Non-Leg Veins 1:00 PM 3:00 PM Phlebology Potpourri 3:30 PM 5:30 PM Nursing Symposium: Sclerotherapy & Compression 3:30 PM 5:30 PM UIP Consensus on Ultrasound Protocols 3:30 PM 5:30 PM Lymphedema: Clinical 3:30 PM 5:30 PM To Bleed or Not to Bleed, That is the Question 3:30 PM 5:30 PM Advanced Imaging 3:30 PM 5:30 PM Leg Ulcers Take Your Best Shot 3:30 PM 5:00 PM Understanding Current Concepts in PTS SATURDAY, NOVEMBER 14, :00 AM 8:00 AM Advanced Management of Venous Thromboembolism 7:00 AM 8:00 AM Iliac Venous Obstruction 7:00 AM 8:00 AM Diagnosis and Management of Venous Malformations 7:00 AM 8:00 AM Non-Thermal Techniques for Saphenous Vein Treatment Hands-On Workshop 7:00 AM 8:00 AM Sclerotherapy Hands-On Workshop 7:00 AM 8:00 AM Pelvic Venous Imaging (Live Scanning) 8:00 AM 9:00 AM Keynote Presentation: Future of Phlebology 10:30 AM 12:00 PM Abstract Session 10:30 AM 12:00 PM Nursing Symposium Practice Management 0 1.5

4 SATURDAY, NOVEMBER 14, 2015 (Continued) 10:30 AM 12:00 PM Ultrasound: Demonstrations 1:00 PM 3:00 PM Nursing Symposium Unique Challenges in Phlebology Part I 1:00 PM 3:00 PM Society for Vascular Ultrasound (SVU) Symposium 1:00 PM 3:00 PM Lymphatic Vascular Diseases: Basic Biology 1:00 PM 3:00 PM Complications of Treatment and How to Manage Them 1:00 PM 3:00 PM Understanding the Literature Making Abstracts Not So Abstract 1:00 PM 3:00 PM Credentialing and Accreditation: What Do You Need and Why? 1:00 PM 3:00 PM Society for Vascular Medicine (SVM) Symposium 3:30 PM 5:30 PM Nursing Symposium Unique Challenges in Phlebology Part II 3:30 PM 5:30 PM Patients with Pathology: Hands On for the Beginner to the Advanced Practitioner 3:30 PM 5:30 PM Lymphatic Vascular Disease: Clinical 3:30 PM 5:30 PM VTE Wait!! There s MORE 3:30 PM 5:30 PM Insurance Challenges in Modern Venous Care 3:30 PM 5:30 PM Special Topics in Venous Disease 3:30 PM 5:30 PM American Venous Forum (AVF) Symposium SUNDAY, NOVEMBER 15, :00 AM 9:00 AM Your Patient is Pregnant, Now What? 8:00 AM 9:00 AM Let s Go to the OR Surgery is Still an Option 8:00 AM 9:00 AM Dermatology for the Phlebologist 8:00 AM 9:00 AM Preserving the Integrity of Our Specialty What Can You Do?

5 SUNDAY, NOVEMBER 15, 2015 (Continued) 9:00 AM 11:00 AM Challenging Cases: Post Mortem Discussion 9:00 AM 3:00 PM Aesthetics Symposium 6 6 For Office Use Only: TOTALS Date Maximum AMA/SVU Earned Nursing Earned Thursday, November 12 7 AMA/SVU 7 Nursing Friday, November AMA/SVU 9 Nursing Saturday, November AMA/SVU 7.5 Nursing Sunday, November 15 7 AMA/SVU 7 Nursing Total 30 AMA/SVU 30.5 Nursing