Check only ONE BOX in following tables.
List American or International Society * :
Check here if you are a member of the Rhinoplasty
Society. Members receive 15% off "Dallas Rhinoplasty"
fees.
*Registration forms must be accompanied by letter from department chair.
(fax to 214-648-4804)
Above lab fees based on 3 participants to a station.
COSMETIC LAB: Please check this box if you would like to pay $300 extra to be in a station with 2 participants.
RHINOPLASTY LAB: Please check this box if you would like to pay $300 extra to be in a station with 2 participants.
If paying by MASTERCARD or VISA credit card:
Card #
(16 digits)
Expiration Date:
/
mm/yyyy
Security code (3 digits):
Amount to be charged:
If paying by AMERICAN EXPRESS credit card:
Card #
(15 digits)
Expiration Date:
/
mm/yy
Security code (4 digits):
Amount to be charged:
Signature(name) of cardholder:
Full mailing address of cardholder:
Street:
City:
State:
Zip/Postal Code
Country:
Today's date: (mm/dd/yyyy)
Complete form. Submit online or print and fax to 214-648-4804 (in USA) or (01)214-648-4804 (international).
If paying by check:
Name on check:
Check number:
Amount:
U.S. Dollars
Make checks payable in U.S. Dollars to:
Continuing Education/UT Southwestern.
Include the reference number #R1003
on the check.
Print the completed form, attach check and mail directly to:
Continuing Education / UT Southwestern
5323 Harry Hines Boulevard
Dallas, Texas 75390-9059
USA
Registration:
The registration fee includes contintental breakfast, lunch, refreshment breaks and all course materials.
NO REGISTRATION SUBSTITUTIONS ARE ALLOWED.
Enrollment
is confirmed upon receipt of registration fee. We
are unable to process any registration without payment.
Please register early. We cannot
guarantee course materials on site to anyone registering
later than February 28, 2010.
Registration confirmation will be sent within 14 days of receipt of the completed registration form and payment. If you do not receive confirmation within the 14 day period, please contact our office at 214-648-3138 or cmeregistrations@utsouthwestern.edu
Refund Policy:
A
handling fee of $200 per symposium will be deducted
from cancellation refunds. Refund requests must be
received by mail or fax prior to February 87, 2010.
No refunds will be made thereafter.
No
changes will be made after February 28, 2010.
Cancellation Policy:
The Office of Contiuing Medical Education reserves the right to limit registration and cancel courses, no less than one week prior to the course, should circumstances make this necessary.
Program Accessibility:
We accommodate people with disabilities. Please call 214-648-3138 for more information, or mark the space indicated above. To ensure accommodation, please register as soon as possible.
The University or Texas Southwestern Medical Center is committed to providing programs and activities to all persons regardless of race, color, national origin, religion, sex, age, veteran status, or disability.
UT Southwestern is an equal opportunity institution.
Questions: Contact DallasRhinoplasty@UTsouthwestern.edu
Anatomy lab participants will receive an anatomic nasal dissection in DVD format during registration at the hotel. DVDs from the previous courses will be available for purchase at the symposium, or you may purchase the DVDs at www.utsouthwestern.edu/plasticsurgerysymposia
Register
prior to January 1, 2010 and receive a FREE DVD
at the course. |
