Register for the AANEM 2017 Annual Meeting

Transcription

1 Register for the AANEM 2017 Annual Meeting Registration for the AANEM Annual Meeting includes all sessions other than workshops, demos, tours, and the Friday social event. Full Registration includes all 4 days of the meeting. Friday/Saturday is limited to sessions on those days. See the list of all the sessions included as part of the registration fee on page 4. Registering online at is the best method. If you prefer to register using this form, use the information below to complete the appropriate registration form. Fees are listed on the form. If you mail or fax the insert, we cannot guarantee your elective sessions will be available when the form is received. Confirmation will be sent to you within 23 business days of receipt of the form. Allow more time for overseas registrations. Confirmation online is immediate. Full Registration and Elective Session Form Color Path Friday/Saturday Registration and Elective Session Form Color Path Physician/Resident & Fellow A Red Path Physician/Resident & Fellow B Orange Path Technologist, Collaborator, Researcher C Green Path Technologist, Collaborator, Researcher D Blue Path Elective Sessions that are charged additional fees include workshops, demos, tours, and the Friday social event. They are included in each of the forms listed above. Note: There are sessions on Form A and B highlighted yellow that are limited attendance sessions and require registration even though there is no fee charged for these sessions. Nonmember Residents, Fellows, Technologists, and Researchers are required to submit additional information outlined below. Medical Students can attend all nonelective sessions at no charge. Proof of enrollment in medical school is required. If you choose to register using this form, follow these steps: Step 1 Fill out the Registrant Information and credit card section. Step 2 (A D) Choose either the Full Registration Fee for access to all 4 days of meeting events (red and green pages), or the Friday/Saturday Only Registration Fee (orange and blue pages). Choose any additional individually priced (elective) sessions you would like to attend. Step 3 Optional Donations General Information All registration fees must be paid in U.S. Dollars. AANEM members to register at AANEM member rates, your membership dues must be paid in full. If your membership dues are not current at the time of registration, nonmember meeting rates will be charged. NonAANEM members join the AANEM and save money on your registration fees! View membership information and rates at Contact the AANEM at if you have questions regarding your registration or aanem@aanem.org. Step 4 Optional Educational Materials (see page 11 in registration guide) Step 5 Fax or mail to the AANEM office NONMEMBERS PhysiciansinTraining: You must submit proof of enrollment verifying your training status with your registration to receive the reduced fee. Nonmember technologists, researchers, and collaborators: You must submit a letter of support from a fellow member with this registration form, you cannot register online. Please contact the AANEM office with questions or become a member at Mail: AANEM 2621 Superior Drive NW Rochester, MN Fax: Phone: meeting@aanem.org

2 1 Registrant Information First Name, Middle Initial Designation Specialty NPI Number Institution/Practice Private Academic Hospital Multispecialty Government Other Birth Date Address Business Home City State Country Zip Buisness Phone Cell Phone Fax is used to communicate important conference information, including conference materials and updates. Check if you have a disability and require some accommodation in order to attend this meeting. You will receive a Disability Accommodation Request Form that needs to be returned to the AANEM by the preregistration deadline. REGISTRANT GUESTS Guests of registrants (family members or significant others) may attend all coffee breaks, the President s Reception, the Abstract Award Winners Reception and the Exhibit Hall* if registered, and wearing an AANEM guest badge. Guest badges will be included with the attendee s registration material. Please Note: There is a fee for each guest. Please include your guest s name/s below., First Name, Middle Initial, First Name, Middle Initial *Children are not allowed in the exhibit hall unsupervised., First Name, Middle Initial Guest Fee Subtotal: Credit Card Information Cardholder Name Card Number Exp CSV Billing Address City State Country Zip Signature >> Continued 1

3 2 Form A: Physician General Registration September 13 Full Registration by 7/5 7/68/16 onsite Amount Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount Member Interactive Approach to EMG W33AB Basic Physician Waveform Recognition (SGD) Resident and Fellow Jumpstart W64AB Basic Resident & Fellow Nonmember Physician Time Workshops Skill Level 875 CME by 950 7/5 7/68/161,025 onsite Amount Autonomic Testing Using EMG Equipment W02A Advanced Resident & Fellow September NM US 13 W18A Basic Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount 8:00 OfficeBased Injection Procedures W20A Basic :00 Interactive Approach to EMG W33AB Basic Waveform Recognition (SGD) Small Group Demo (SGD) 8:00 Skin Biopsy Technique & Applications W22A Basic :00 Resident and Fellow Jumpstart W64AB Basic :00 Gait Disorders in NM Disease W41A Basic :00 NCS Workshop Paraspinal Mapping/Lumbosacral Plexopathy W62W1 W46A MultiLevel Basic Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount 8:00 8:00 8:00 8:00 Autonomic EMG Laryngeal Testing Using EMG Equipment W02A W08A Advanced NM EMG USand US Respiratory W18A W11A Basic Advanced OfficeBased US MSK Lower Injection Extremity Procedures W20A W57A Basic Advanced Skin US Lower Biopsy Extremity Technique Nerves & Applications and Muscles W22A W61A Basic Advanced :00 Time Gait Workshops Disorders in NM Disease W41A Basic Skill Level 1.50 CME by 115 7/5 7/68/ onsite 165 Amount 10:30 Autonomic Testing Using EMG Equipment W02B Advanced :00 12:00 PM Paraspinal Mapping/Lumbosacral Plexopathy W46A Basic :30 EMG Muscle ID W09B Basic :00 12:00 PM EMG Laryngeal W08A Advanced :30 NM US W18B Basic :00 12:00 PM EMG and US Respiratory W11A Advanced :30 OfficeBased Injection Procedures W20B Basic :00 12:00 PM US MSK Lower Extremity W57A Advanced :30 Gait Disorders in NM Disease W41B Basic :00 12:00 PM US Lower Extremity Nerves and Muscles W61A Advanced :30 Paraspinal Mapping/Lumbosacral Plexopathy W46B Basic Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount 10:30 10:30 10:30 10:30 Autonomic US Guidance Testing for Neurotoxins Using EMG Equipment W02B W59B Advanced Basic EMG US Upper Muscle Extremity ID Nerves and Plexus W09B W58B Basic Advanced NM US US Lower Extremity Nerves and Muscles W18B W61B Basic Advanced OfficeBased Expert US Injection Procedures W20B W70B Basic Advanced :30 Time Gait Workshops Disorders in NM Disease W41B Basic Skill Level 1.50 CME by 115 7/5 7/68/ onsite 165 Amount EMG Needle Basics W10C Basic :30 Paraspinal Mapping/Lumbosacral Plexopathy W46B Basic Short Segment NCS W12C Basic :30 US Guidance for Neurotoxins W59B Basic NM US W18C Basic :30 US Upper Extremity Nerves and Plexus W58B Advanced NCS Pitfalls W21C Basic :30 US Lower Extremity Nerves and Muscles W61B Advanced Repetitive Nerve Stimulation W27C Basic :30 Expert US W70B Advanced Myopathies: EDX Approach W55C Basic Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount :30 PM Annual Meeting Registration Form NCS Workshop W62W1 MultiLevel EMG Needle Basics W10C Basic Short Segment NCS W12C Basic

4 10:30 Expert US W70B Advanced Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount EMG Needle Basics W10C Basic Short Segment NCS W12C Basic NM US W18C Basic NCS Pitfalls W21C Basic Repetitive Nerve Stimulation W27C Basic Myopathies: EDX Approach W55C Basic Cranial NCS and EMG Testing W05C Advanced Annual Meeting 165 Registration Form Cranial EDX/Rehab NCS Approach and EMG in Testing OB Brachial Plexus W05C W56C Advanced :00 1:30 PM Palsy Cranial NCS and EMG Testing W05C Advanced EDX/Rehab US Upper Extremity Approach Nerves in OB and Brachial Plexus Plexus W56C W58C Advanced :00 1:30 PM Palsy EDX/Rehab Approach in OB Brachial Plexus W56C Advanced Palsy US Upper MSK Upper Extremity Extremity Nerves and Plexus W58C W60C Advanced :00 1:30 PM US Upper Extremity Nerves and Plexus W58C Advanced :30 TimePM US Special MSK Upper Sessions Extremity W60C Skill Advanced Level CME 1.50 by 115 7/5 7/68/ onsite 165 Amount 3:00 1:30 PM US MSK Upper Extremity W60C Advanced :00 3:00 PM EvidenceBased Medicine Session MultiLevel Time Limited to to first attendees Skill Level CME by 7/5 7/68/16 onsite Amount Time Skill Level CME by 7/5 7/68/16 onsite Amount 8:00 Friday, EvidenceBased Medicine Session September 15 MultiLevel :00 8:00 PM Limited EvidenceBased to first 50 Medicine attendees Session MultiLevel Time Limited Special to first Sessions 50 attendees Skill Level CME by 7/5 7/68/16 onsite Amount Friday, 15 1:30 Friday, PM September Challenging 15 Cases Roundtable MultiLevel Time Limited to first 50 attendees Skill Level CME by 7/5 7/68/16 onsite Amount Time Skill Level CME by 7/5 7/68/16 onsite Amount 1:30 Saturday, Challenging Cases Roundtable September NM Prep 16 Course MultiLevel 1:30 Challenging Cases Roundtable Basic :00 5:30 PM PM Limited to first 50 attendees MultiLevel Time Workshops Limited to first 50 attendees Skill Level CME by 7/5 7/68/16 onsite Amount Saturday, September 16 Saturday, September Entrapment 16 Lower Limb W13AS Basic Time Workshops EDX Prep Course Skill Basic Level CME 0 by 0 7/5 7/68/16 0 onsite 0 Amount Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount 8:00 Time Entrapment Repetitive Workshops Nerve Lower Stimulation Limb W13AS W27AS Basic Skill Level CME 1.50 by 115 7/5 7/68/ onsite 165 Amount Entrapment Lower Limb W13AS Basic :00 Entrapment Lower Limb W13AS Repetitive Ulnar Techniques Nerve Stimulation W27AS W32AS Basic Repetitive Nerve Stimulation W27AS Basic :00 Repetitive Nerve Stimulation W27AS Ulnar Cervical Techniques Radiculopathy/Brachial Plexopathy W32AS W45AS Basic Ulnar Techniques W32AS Basic :00 Ulnar Techniques W32AS Cervical Measuring Radiculopathy/Brachial Jitter With Concentric Plexopathy Electrodes W45AS W07AS Advanced Basic Cervical Radiculopathy/Brachial Plexopathy W45AS Basic :00 Cervical Radiculopathy/Brachial Plexopathy W45AS Basic Measuring EMG Evaluation Jitter With of Tremor Concentric Electrodes W07AS W17AS Advanced Measuring Jitter With Concentric Electrodes W07AS Advanced :00 Measuring Jitter With Concentric Electrodes W07AS EMG NCS Uncommon Evaluation of Tremor W17AS W23AS Advanced EMG Evaluation of Tremor W17AS Advanced :00 EMG Evaluation of Tremor W17AS NCS Pelvic Uncommon Floor EMG W23AS W24AS Advanced NCS Uncommon W23AS Advanced :00 NCS Uncommon W23AS Pelvic Advanced Floor Autonomic EMG Testing W24AS W50AS Advanced Pelvic Floor EMG W24AS Advanced :00 Pelvic Floor EMG W24AS Advanced Most Reliable Autonomic Techniques Testing for CTS EDX W50AS W53AS Advanced Advanced Autonomic Testing W50AS Advanced :00 Advanced Autonomic Testing W50AS Most Neonatal Reliable Brachial Techniques Plexopathy for CTS EDX W53AS W71AS Advanced Most Reliable Techniques for CTS EDX W53AS Advanced :00 Most Reliable Techniques for CTS EDX W53AS Neonatal SFEMG Basic/Advanced Brachial Plexopathy W71AS W31AS MultiLevel Advanced Neonatal Brachial Plexopathy W71AS Advanced SFEMG Neonatal Basic/Advanced Brachial Plexopathy W31AS W71AS MultiLevel Advanced :00 SFEMG Basic/Advanced W31AS MultiLevel # 165 Amount 8:00 9:30 SFEMG Basic/Advanced W31AS MultiLevel :30 Tours & 1:00 PM 17CTW Shopping Cost: 45 per person # Amount # Amount September 13 5:00 PM Tours Social & Events Social Event # # Amount Thursday, September 1:00 17CTW 17CTR1 Shopping Grand Canyon Cost: Tour 45 per Cost: person 145 per person September :00 8:00 1:00 PM 17CTW Shopping Cost: 45 per person September 13 5:00 PM Thursday, Friday, September September 15 17CTR1 17CTF1 Sedona Grand Canyon Cost: Tour 90 per Cost: person 145 per person 14 Thursday, September 8:00 17CTR1 Grand Canyon Tour Cost: 145 per person 14 17CTF1 Sedona Cost: 90 per person 4:00 17CTF1 Sedona Cost: 90 per person 6:30 PM Astronomy and Gastronomy on the Ballroom Lawn Cost: 125/per person 3

5 Fri./Sat. Registration by 7/5 7/68/16 onsite Amount Member Physician Resident & Fellow Nonmember Form B: Physician Friday/Saturday Only Registration Physician Form B: Physician Friday/Saturday Only Registration Resident & Fellow Form B: Physician Friday/Saturday Only Registration Time AFF5 Friday, September Special 15 Sessions Skill Level CME by 7/5 7/68/16 onsite Amount Challenging Cases Roundtable AFF5 MultiLevel Time AFF5 Skill Level CME by 7/5 7/68/16 onsite Limited to first 50 attendees Amount 1:30 Saturday, Challenging Cases Roundtable September NM Prep 16 Course AFF5 MultiLevel :00 5:30 PM PM Limited to first 50 attendees Basic Time Workshops Skill Level CME by 7/5 7/68/16 onsite Amount Saturday, September 16 8:00 PM Entrapment Lower Limb W13AS Basic Time Workshops EDX Prep Course Skill BasicLevel CME 0 by 0 7/5 7/68/16 0 onsite 0 Amount 8:00 Time Entrapment Repetitive Workshops Nerve Lower Stimulation Limb W27AS W13AS Basic Skill Level CME 1.50 by 115 7/5 7/68/ onsite 165 Amount 8:00 Entrapment Lower Limb W13AS Basic :00 Repetitive Ulnar Techniques Nerve Stimulation W32AS W27AS Basic :00 Repetitive Nerve Stimulation W27AS Basic :00 Ulnar Cervical Techniques Radiculopathy/Brachial Plexopathy W45AS W32AS Basic :00 Ulnar Techniques W32AS Basic :00 Cervical Measuring Radiculopathy/Brachial Jitter With Concentric Plexopathy Electrodes W07AS W45AS Advanced Basic :00 Cervical Radiculopathy/Brachial Plexopathy W45AS Basic :00 Measuring EMG Evaluation Jitter With of Tremor Concentric Electrodes W17AS W07AS Advanced :00 Measuring Jitter With Concentric Electrodes W07AS Advanced :00 EMG NCS Uncommon Evaluation of Tremor W23AS W17AS Advanced :00 EMG Evaluation of Tremor W17AS Advanced :00 NCS Pelvic Uncommon Floor EMG W24AS W23AS Advanced :00 NCS Uncommon W23AS Advanced :00 9:30 Pelvic Advanced Floor Autonomic EMG Testing W50AS W24AS Advanced Pelvic Floor EMG W24AS Advanced :00 9:30 Advanced Most Reliable Autonomic Techniques Testing for CTS EDX W53AS W50AS Advanced Advanced Autonomic Testing W50AS Advanced :00 9:30 Most Neonatal Reliable Brachial Techniques Plexopathy for CTS EDX W71AS W53AS Advanced Most Reliable Techniques for CTS EDX W53AS Advanced :00 9:30 Neonatal SFEMG Basic/Advanced Brachial Plexopathy W31AS W71AS MultiLevel Advanced Neonatal Brachial Plexopathy W71AS Advanced :00 9:30 Tours & SFEMG Basic/Advanced W31AS MultiLevel # Amount 9:30 Social Events 8:00 SFEMG Basic/Advanced W31AS MultiLevel Friday, 9:30 September 15 17CTF1 Sedona Cost: 90 per person # Amount # Amount Friday, Social September Events 15 17CTF1 Sedona Cost: 90 per person 17CTF1 Sedona Cost: 90 per person 6:30 PM Astronomy and Gastronomy on the Ballroom Lawn Cost: 125/per person 4

6 Form C: Technologist/Collaborator/Researcher General Registration Full Registration by 7/5 7/68/16 onsite Amount September 13 Time Member Workshops Skill Level CEU by 7/5 7/68/16 onsite Amount NCS Workshop W62W1 MultiLevel Technologist, Collaborator, Researcher Time Workshops Skill Level CEU by 7/5 7/68/16 onsite Amount Nonmember NM US W18A Basic :30 Technologist, Collaborator, Researcher Gait Disorders in NM Disease W41A Basic September 13 US MSK Lower Extremity W57A Advanced Time Workshops Skill Level CEU by 7/5 7/68/16 onsite Amount 12:00 PM NCS US Lower Workshop Extremity Nerves and Muscles W62W1 W61A MultiLevel Advanced Time Workshops Skill Level CEU by 7/5 7/68/16 onsite Amount 8:00 10:30 12:00 PM 8:00 10:30 12:00 PM 8:00 10:30 12:00 PM 8:00 10:30 12:00 PM NM US W18A W18B Basic Gait Disorders in NM Disease W41A W41B Basic US MSK Upper Lower Extremity Extremity Nerves and Plexus W57A W58B Advanced US Lower Extremity Nerves and Muscles W61A W61B Advanced Time 10:30 Workshops Expert US W70B Skill Advanced Level CEU 1.50 by 115 7/5 7/68/ onsite 165 Amount 10:30 NM US W18B Basic :00 Time PM Workshops Skill Level CEU by 7/5 7/68/16 onsite Amount 10:30 1:30 PM 12:00 PM 10:30 1:30 PM 12:00 PM 10:30 1:30 PM 12:00 PM 10:30 1:30 PM 12:00 PM Gait Short Disorders Segment in NCS NM Disease W41B W12C Basic US NM Upper US Extremity Nerves and Plexus W58B W18C Advanced Basic US NCS Lower Pitfalls Extremity Nerves and Muscles W61B W21C Advanced Basic Expert Repetitive US Nerve Stimulation W70B W27C Advanced Basic Time Workshops Cranial NCS and EMG Testing W05C Skill Advanced Level CEU 1.50 by 115 7/5 7/68/ onsite 165 Amount Short Segment NCS W12C Basic :30 US Upper Extremity Nerves and Plexus W58C Advanced NM US W18C Basic :30 US MSK Upper Extremity W60C Advanced NCS Pitfalls W21C Basic Saturday, September 16 1:30 TimePM Repetitive Workshops Nerve Stimulation W27C Basic Skill Level CEU 1.50 by 115 7/5 7/68/ onsite 165 Amount Repetitive Nerve Stimulation W27AS Basic :30 Cranial NCS and EMG Testing W05C Advanced Ulnar Techniques W32AS Basic :30 US Upper Extremity Nerves and Plexus W58C Advanced Cervical Radiculopathy/Brachial Plexopathy W45AS Basic :30 US MSK Upper Extremity W60C Advanced NCS Uncommon W23AS Advanced Saturday, September 16 Time Workshops Advanced Autonomic Testing W50AS Skill Advanced Level CEU 1.50 by 115 7/5 7/68/ onsite 165 Amount Repetitive Nerve Stimulation W27AS Basic :00 Most Reliable Techniques for CTS EDX W53AS Advanced :00 9:30 Ulnar Techniques W32AS Basic # Amount Cervical Radiculopathy/Brachial Plexopathy W45AS Basic :00 PM 17CTW Shopping Cost: 45 per person 8:00 September 13 NCS 5:00 Uncommon PM W23AS Advanced Thursday, September 17CTR1 Grand Canyon Tour Cost: 145 per person 8:00 14 Advanced Autonomic Testing W50AS Advanced :30 17CTF1 Sedona Cost: 90 per person Most 4:00 Reliable PM Techniques for CTS EDX W53AS Advanced Social Annual Events Meeting Registration Form September 13 1:00 PM 5:00 PM 5 17CTW Shopping Cost: 45 per person # Amount

7 September 13 Thursday, September 14 NCS Uncommon W23AS Advanced Advanced Autonomic Testing W50AS Advanced Most Reliable Techniques for CTS EDX W53AS Advanced :00 PM 5:00 PM 6:30 PM 17CTW Shopping Cost: 45 per person 17CTR1 Grand Canyon Tour Cost: 145 per person 17CTF1 Sedona Cost: 90 per person Astronomy and Gastronomy on the Ballroom Lawn Cost: 125/per person # Amount Form D: Technologist/Collaborator/Researcher Friday/Saturday Only Registration Friday/Saturday Registration By 7/5 7/68/16 onsite Amount Saturday, September 16 Member Time Workshops Skill Level CEU by 7/5 7/68/16 onsite Amount 8:00 Technologist, Collaborator, Repetitive Nerve Researcher Stimulation W27AS Basic Nonmember 8:00 Technologist, Collaborator, Cervical Radiculopathy/Brachial Researcher Plexopathy W45AS Basic Saturday, September NCS 16 Uncommon W23AS Advanced Time Workshops Advanced Autonomic Testing W50AS Skill Level Advanced CEU 1.50 by 7/ /68/ onsite 165 Amount 8:00 Repetitive Nerve Stimulation W27AS Basic Most Reliable Techniques for CTS EDX W53AS Advanced :00 Social Ulnar Techniques W32AS Basic # Amount 8:00 Events Cervical Radiculopathy/Brachial Plexopathy W45AS Basic CTF1 Sedona Cost: 90 per person NCS 4:00 Uncommon PM W23AS Advanced Social Events Ulnar Techniques W32AS Basic Advanced Autonomic Testing W50AS Advanced Most Reliable Techniques for CTS EDX W53AS Advanced :30 PM 17CTF1 Sedona Cost: 90 per person Astronomy and Gastronomy on the Ballroom Lawn Cost: 125/per person # Amount 6

8 3 Optional Donations AANEM Advocacy monitors and advocates on issues that affect the practice of NM and EDX medicine, ensuring patients receive quality care and members receive appropriate reimbursement. Advocacy Contribution The AANEM Foundation funds research awards, fellowships, and education in the area of EDX/NM medicine, to help improve patient care and quality of life for patients with muscle and nerve disorders. Foundation Contribution Donation Subtotal: 4 Optional Educational Materials See page 10 &11 for details Educational Product Info: 2017 Annual Meeting Collection Digital Download Introductory price 200 with meeting registration (300 onsite) Workshop EBundle Downloadable PDF of over 45 workshop handouts Introductory price 50 with meeting registration (75 onsite) Nonmember Physician SelfAssessment MOC 50/per course (Please check no more than 1 course per day below) Wednesday 1:30 PM Basics With the Experts Thursday 1:30 PM Neuropathy Course and Autonomics Friday 1:30 PM Peripheral Neuropathy Friday 1:30 PM ALS Friday 1:30 PM Systemic Complications of NMD Nonmember CNCT Checkpoint Technologist 50 5 Total Registration Fee Guest Fee Elective Session Fee Donations Educational Materials (page 11 of registration guide) Nonmember MOC Total Fee You may attach a check in the amount of your total fee or fill out the form on page 1 of this insert to pay by credit card. Education Products Subtotal: Is your registration complete? 1. Registrant information section is completed 2. Choose ONE registration type based on the full registration or Friday/Saturday 3. Indicate if you d like to make a donation to AANEM Advocacy or the AANEM Foundation or want to purchase educational materials 4. Doublecheck all fee calculations to avoid delays in registration processing 5. Credit card information or check payment is included with registration 6. Last name is written on the bottom of each registration page 7